Basic Information
| Provider Information | |||||||||
| NPI: | 1336736594 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORT COLLINS YOUTH CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7328 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706632742 | ||||||||
| FaxNumber: | 9703422093 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 ROCKY MOUNTAIN AVE # 260 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702679510 | ||||||||
| FaxNumber: | 9702079967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2020 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FRED | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9702679510 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.