Basic Information
| Provider Information | |||||||||
| NPI: | 1225347339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTROSE COUNTY SCHOOL DISTRICT RE-1J | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHSIDE CHILD HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2233 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702493700 | ||||||||
| FaxNumber: | 9704978410 | ||||||||
| Practice Location | |||||||||
| Address1: | 528 N UNCOMPAHGRE AVE | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702406438 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2010 | ||||||||
| LastUpdateDate: | 11/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | SLATER | ||||||||
| AuthorizedOfficialFirstName: | KARIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9702527921 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MONTROSE COUNTY SCHOOL DISTRICT RE-1J | ||||||||
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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 | 83121285 | 05 | CO | MEDICAID | 05134064 | 05 | CO | MEDICAID |