Basic Information
| Provider Information | |||||||||
| NPI: | 1639767239 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VVMC DIVERSIFIED SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VAIL HEALTH CLINIC EAGLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40000 | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816587520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704797272 | ||||||||
| FaxNumber: | 9704706548 | ||||||||
| Practice Location | |||||||||
| Address1: | 377 SYLVAN LAKE RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816316779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2021 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HIGGINS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9704795131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VVMC DIVERSIFIED SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.