Basic Information
| Provider Information | |||||||||
| NPI: | 1295381390 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VAIL CLINIC INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | HOWARD HEAD SPORTS MEDICINE AT AVON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40000 | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816587520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704797272 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 126 RIVERFRONT LN UNIT C107 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816206860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708459600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2019 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HIGGINS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 9704795131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VAIL CLINIC INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.