Basic Information
| Provider Information | |||||||||
| NPI: | 1760443709 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PVHS/TIMBERLINE, LLC | ||||||||
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| OtherOrganizationName: | TIMBERLINE MEDICAL, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 STANLEY AVE | ||||||||
| Address2: | STE 202 | ||||||||
| City: | ESTES PARK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805176363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705862343 | ||||||||
| FaxNumber: | 9705869060 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 STANLEY AVE | ||||||||
| Address2: | STE 202 | ||||||||
| City: | ESTES PARK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805176363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705862343 | ||||||||
| FaxNumber: | 9705869060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | SELL PREMER | ||||||||
| AuthorizedOfficialFirstName: | SHARI | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9705862343 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12383376 | 05 | CO | MEDICAID |