Basic Information
| Provider Information | |||||||||
| NPI: | 1083642680 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH COLORADO FAMILY MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 N CENTRAL AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122702 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 23RD AVE | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806346070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027474000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | LARAWAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 04021291 | 05 | CO | MEDICAID |