Basic Information
Provider Information | |||||||||
NPI: | 1295732048 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUNRISE COMMUNITY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MONFORT FAMILY CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2930 11TH AVE | ||||||||
Address2: |   | ||||||||
City: | EVANS | ||||||||
State: | CO | ||||||||
PostalCode: | 806201011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9703539403 | ||||||||
FaxNumber: | 9703539906 | ||||||||
Practice Location | |||||||||
Address1: | 2930 11TH AVE | ||||||||
Address2: |   | ||||||||
City: | EVANS | ||||||||
State: | CO | ||||||||
PostalCode: | 806201011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9703539403 | ||||||||
FaxNumber: | 9703539906 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORAN | ||||||||
AuthorizedOfficialFirstName: | MITZI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9703504606 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Legal Medicine |   | 261QF0400X |   | CO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 05638283 | 05 | CO |   | MEDICAID |