1386973204 NPI number — NEEDLEROCK FAMILY HEALTH CLINIC

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 1386973204 NPI number — NEEDLEROCK FAMILY HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEEDLEROCK FAMILY HEALTH CLINIC
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:
1386973204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRAWFORD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81415-0104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-812-6403
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 ELM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRAWFORD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81415-5011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-812-6403
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/24/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
JENNY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
970-812-6403

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  178811 , 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)

  • Identifier: 78255856 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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