Basic Information
| Provider Information | |||||||||
| NPI: | 1033701255 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEDAR POINT HEALTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702497751 | ||||||||
| FaxNumber: | 9702495029 | ||||||||
| Practice Location | |||||||||
| Address1: | 836 S TOWNSEND AVE STE A | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706159120 | ||||||||
| FaxNumber: | 9702401139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2021 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | CORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9702497751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CEDAR POINT HEALTH LLC | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9000160481 | 05 | CO | MEDICAID |