1730576844 NPI number — FOUR CORNERS NATUROPATHIC

Table of content: (NPI 1730576844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730576844 NPI number — FOUR CORNERS NATUROPATHIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR CORNERS NATUROPATHIC
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:
1730576844
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
545 E 31ST ST
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:
81301-4335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-799-8961
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
48 COUNTY ROAD 250 UNIT 7
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:
81301-8848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-799-8961
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/16/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOE
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
ND LPC RN
Authorized Official Telephone Number:
970-799-8961

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  0012355 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: 0171869 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X , with the licence number: 0000026 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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