Basic Information
| Provider Information | |||||||||
| NPI: | 1407012826 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERON LAKE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FOXTRAIL FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE | ||||||||
| Address2: | STE 150 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805388702 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1625 FOXTRAIL DR | ||||||||
| Address2: | STE 190 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706196900 | ||||||||
| FaxNumber: | 9706196990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 01/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | DOUGHTY | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9702377003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HERON LAKE LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 92181031 | 05 | CO | MEDICAID |