Basic Information
| Provider Information | |||||||||
| NPI: | 1760492714 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POUDRE VALLEY HEALTH CARE INC. | ||||||||
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| OtherOrganizationName: | POUDRE VALLEY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706244443 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1024 S LEMAY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805243929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704957000 | ||||||||
| FaxNumber: | 9704957663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIEBER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | DANIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7208487836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 273R00000X | N | Hospital Units | Psychiatric Unit | 273Y00000X | N | Hospital Units | Rehabilitation Unit | 343900000X | N | Transportation Services | Non-emergency Medical Transport (VAN) | 333600000X | 010305 | CO | N | Suppliers | Pharmacy | 341600000X | CO | N | Transportation Services | Ambulance | 282N00000X | 0050 | CO | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 81933762 | 05 | CO | MEDICAID | 86373251 | 01 | CO | MEDICAID RTCF | OTHER | 0694280 | 01 | CO | AETNA | OTHER | 618515 | 01 | CO | STATE FARM | OTHER | 00025PO | 01 | CO | BLUE CROSS COLORADO | OTHER | 06060123 | 05 | CO | MEDICAID | 6160355 | 01 | CO | AMERICA'S HEALTH PLAN | OTHER | DE0901 | 01 | CO | RAILROAD MEDICARE | OTHER | 05010004 | 05 | CO | MEDICAID | 96934832 | 01 | CO | COLORADO INDIGENT | OTHER | H188 | 01 | CO | MIDLANDS CHOICE | OTHER | 44054 | 01 | CO | GOV EMPLOYEE HOSPITAL ASS | OTHER | B001 | 01 | CO | TRICARE WPS | OTHER | D8004 | 01 | CO | MEDICARE PART B | OTHER | 1192523-00 | 05 | WY | MEDICAID | 75276 | 01 | CO | WORLD INSURANCE | OTHER |