1720301344 NPI number — YOUR FAMILY MEDICAL HOME,PLLC

Table of content: (NPI 1720301344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720301344 NPI number — YOUR FAMILY MEDICAL HOME,PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOUR FAMILY MEDICAL HOME,PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720301344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5620
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRECKENRIDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80424-5620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-238-7070
Provider Business Mailing Address Fax Number:
970-423-5332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
435 N PARK AV
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
BRECKENRIDGE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-238-7070
Provider Business Practice Location Address Fax Number:
970-453-5332
Provider Enumeration Date:
03/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ZAITZ
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
925-597-0121

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  31975 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01319755 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81751737 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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