1861618191 NPI number — TIMBERLINE CLINIC, INC.

Table of content: (NPI 1861618191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861618191 NPI number — TIMBERLINE CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIMBERLINE CLINIC, 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:
1861618191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 723
Provider Second Line Business Mailing Address:
980 MAIN ST.
Provider Business Mailing Address City Name:
FAIRPLAY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80440-0723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-836-3455
Provider Business Mailing Address Fax Number:
719-836-1792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
980 MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRPLAY
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80440-0723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-836-3455
Provider Business Practice Location Address Fax Number:
719-836-1792
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
719-836-3455

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  43262 , 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: 01 . This is a "CO PACIFICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 500000326 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: SH29090 . This is a "CO BLUE SHIELD" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 04008850 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07100753 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: YO634320 . This is a "CO BLUE SHIELD" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 01219609 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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