Basic Information
| Provider Information | |||||||||
| NPI: | 1144535444 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POUDRE VALLEY HEALTH CARE, INC | ||||||||
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| OtherOrganizationName: | POUDRE VALLEY HOSPITAL FAMILY MEDICINE CENTER WALK IN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 E HARMONY RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805288620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702377000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1025 PENNOCK PL | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805243257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704958980 | ||||||||
| FaxNumber: | 9704958988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2010 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | RIEBER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | DANIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 7208487836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POUDRE VALLEY HEALTH CARE INC | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QA0005X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Family Planning Facility | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | CD3123 | 01 | CO | MEDICARE RAILROAD | OTHER | 40486061 | 05 | CO | MEDICAID |