Basic Information
| Provider Information | |||||||||
| NPI: | 1841325974 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POUDRE VALLEY HEALTH CARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | POUDRE VALLEY HOSPITAL OCC UPATIONAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 E. LOWRY BLVD | ||||||||
| Address2: | F402, 3RD FLOOR | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205531700 | ||||||||
| FaxNumber: | 7205531754 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 OAKRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805255564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704958450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIEBER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | DANIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 7208487836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POUDRE VALLEY HEALTH CARE INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8426297100 | 05 | NE | MEDICAID | CE9908 | 01 | CO | MEDICARE PART B GROUP # | OTHER | 0501004 | 05 | CO | MEDICAID | 119253-00 | 05 | WY | MEDICAID |