Basic Information
| Provider Information | |||||||||
| NPI: | 1619152576 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAINLAND PEDICATRICS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1870 W 122ND AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802342075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038533500 | ||||||||
| FaxNumber: | 3034269340 | ||||||||
| Practice Location | |||||||||
| Address1: | 8889 FOX DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802608841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034300823 | ||||||||
| FaxNumber: | 3034269581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2008 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | DOUCET | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 3038533500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY REACH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25750 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.