1235310285 NPI number — STONEY MESA FAMILY PRACTICE INC

Table of content: (NPI 1235310285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235310285 NPI number — STONEY MESA FAMILY PRACTICE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONEY MESA FAMILY PRACTICE INC
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:
1235310285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELTA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81416-1129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-874-2470
Provider Business Mailing Address Fax Number:
970-874-2475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1722 HILLCREST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELTA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81416-2810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-874-5061
Provider Business Practice Location Address Fax Number:
970-874-5074
Provider Enumeration Date:
11/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PURVIS
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
970-874-5061

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  39111 , 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: 83777865 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: ST802592 . This is a "BCBS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com