Basic Information
| Provider Information | |||||||||
| NPI: | 1124432828 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POUDRE VALLEY HEALTH CARE, INC | ||||||||
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| OtherOrganizationName: | POUDRE VALLEY HOSPITAL PALLIATIVE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805388702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706244443 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1024 S LEMAY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805243929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704958369 | ||||||||
| FaxNumber: | 9704957492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2014 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | RIEBER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | DANIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 7208487836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POUDRE VALLEY HEALTH CARE, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1124432828 | 05 | CO | MEDICAID |