Basic Information
| Provider Information | |||||||||
| NPI: | 1417444043 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER RURAL FAMILY MEDICAL & DENTAL CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 S WEBER ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196345700 | ||||||||
| FaxNumber: | 7196338477 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 TELLER COUNTY ROAD 1 | ||||||||
| Address2: | |||||||||
| City: | CRIPPLE CREEK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195087686 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 04/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROBERS | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ATTORNEY | ||||||||
| AuthorizedOfficialTelephone: | 7196345700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.