1417279597 NPI number — ROARING FORK NEUROLOGY, P.C.

Table of content: (NPI 1417279597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417279597 NPI number — ROARING FORK NEUROLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROARING FORK NEUROLOGY, P.C.
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:
1417279597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 MARKET ST UNIT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BASALT
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81621-7410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-379-0452
Provider Business Mailing Address Fax Number:
970-422-7123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 MARKET ST UNIT 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BASALT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81621-7410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-927-1141
Provider Business Practice Location Address Fax Number:
970-422-7123
Provider Enumeration Date:
02/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
ALISON
Authorized Official Middle Name:
BIBLE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
970-927-1141

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  48812 , 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: 48812 . This is a "CO MED LIC" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 1285780874 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com