Basic Information
Provider Information | |||||||||
NPI: | 1184659377 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IBACH | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: | P | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNS, RXN, APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PARADIS | ||||||||
OtherFirstName: | CAROL | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1208 | ||||||||
Address2: |   | ||||||||
City: | MONTROSE | ||||||||
State: | CO | ||||||||
PostalCode: | 814021208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702523200 | ||||||||
FaxNumber: | 9702523208 | ||||||||
Practice Location | |||||||||
Address1: | 605 E MIAMI RD | ||||||||
Address2: |   | ||||||||
City: | MONTROSE | ||||||||
State: | CO | ||||||||
PostalCode: | 81401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702499694 | ||||||||
FaxNumber: | 9702492955 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 08/28/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0812X | 46632 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Community |
ID Information
ID | Type | State | Issuer | Description | 84-0561224 | 01 | CO | TAX ID | OTHER |