1316120991 NPI number — NEPHROLOGY CLINIC PC

Table of content: (NPI 1316120991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316120991 NPI number — NEPHROLOGY CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEPHROLOGY CLINIC PC
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:
THE NEPHROLOGY CLINIC
Provider Other Organization Name Type Code:
3
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:
1316120991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 SPECHT POINT RD
Provider Second Line Business Mailing Address:
SUITE 127
Provider Business Mailing Address City Name:
FT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80525-4311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-493-7733
Provider Business Mailing Address Fax Number:
970-493-8745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3116 WILLET DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARAMIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-493-7733
Provider Business Practice Location Address Fax Number:
970-493-8745
Provider Enumeration Date:
12/06/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MIKULA
Authorized Official First Name:
TOBEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
970-493-7733

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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