Basic Information
| Provider Information | |||||||||
| NPI: | 1679660732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHC-FORT MORGAN INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLORADO PLAINS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 SEVEN SPRINGS WAY | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159207000 | ||||||||
| FaxNumber: | 6159208913 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 LINCOLN ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FORT MORGAN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807013290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708673013 | ||||||||
| FaxNumber: | 9708675951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 07/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | GIOVANETTI | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6159207000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 642204 | 01 | CO | BCBS | OTHER | 85530841 | 05 | CO | MEDICAID |