1770564908 NPI number — NORTHERN COLORADO GERIATRICS

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 1770564908 NPI number — NORTHERN COLORADO GERIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN COLORADO GERIATRICS
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:
1770564908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2519 S SHIELDS ST
Provider Second Line Business Mailing Address:
PMB I-143
Provider Business Mailing Address City Name:
FT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80526-1855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-388-3279
Provider Business Mailing Address Fax Number:
970-419-4780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2519 S SHIELDS ST
Provider Second Line Business Practice Location Address:
PMB I-143
Provider Business Practice Location Address City Name:
FT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80526-1855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-388-3279
Provider Business Practice Location Address Fax Number:
970-419-4780
Provider Enumeration Date:
11/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MEURER
Authorized Official First Name:
TAMRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
970-388-3279

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  76875 , 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: 80627544 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: DB5993 . This is a "RR MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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