1588008254 NPI number — MELLYNA ANGELICA MCGLOTHLIN D.O.

Table of content: MELLYNA ANGELICA MCGLOTHLIN D.O. (NPI 1588008254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588008254 NPI number — MELLYNA ANGELICA MCGLOTHLIN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGLOTHLIN
Provider First Name:
MELLYNA
Provider Middle Name:
ANGELICA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARTER
Provider Other First Name:
MELLYNA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588008254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1113 OAKRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80525-5591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-225-0040
Provider Business Mailing Address Fax Number:
970-225-2996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1113 OAKRIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80525-5591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-225-0040
Provider Business Practice Location Address Fax Number:
970-225-2996
Provider Enumeration Date:
04/24/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  54577 , 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)





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