Basic Information
| Provider Information | |||||||||
| NPI: | 1285380188 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VAIL CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40000 | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816587520 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 377 SYLVAN LAKE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816316779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761225 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2022 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | HIGGINS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3036895275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VAIL CLINIC, INC. | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.