1104085737 NPI number — RIVERGATE NATURAL HEALTHCARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104085737 NPI number — RIVERGATE NATURAL HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERGATE NATURAL HEALTHCARE
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:
1104085737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 RIVERGATE STE B1-108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURANGO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81301-7473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-382-9100
Provider Business Mailing Address Fax Number:
970-385-4187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 RIVERGATE STE B1-108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURANGO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81301-7473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-382-9100
Provider Business Practice Location Address Fax Number:
970-385-4187
Provider Enumeration Date:
06/09/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LUM
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
JENNIFER
Authorized Official Title or Position:
HEALTH CARE PROVIDER/OWNER
Authorized Official Telephone Number:
970-382-9100

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  029664 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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