Full Name | |
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Speciality | Clinic/Center |
Location | 908 S Oak, La Veta, Colorado |
Authorized Official Name and Position | Colette C Martin (CFO) |
Authorized Official Contact | 7197385137 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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23500 Us Highway 160 Walsenburg CO 81089-9524 Ph: (719) 738-5135 | 908 S Oak La Veta CO 81055-0704 Ph: (719) 742-4560 |
NPI Number | 1760851737 |
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Provider Enumeration Date | 09/21/2015 |
Last Update Date | 07/25/2022 |
Medicare PECOS PAC ID | 4789591769 |
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Medicare Enrollment ID | O20170106000946 |
Identifier | Type | State | Issuer |
---|---|---|---|
1760851737 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
Provider Name | Grant M Taylor |
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Provider Type | Practitioner - Family Practice |
Provider Identifiers | NPI Number: 1417963349 PECOS PAC ID: 4082501242 Enrollment ID: I20040302000829 |
Provider Name | Leslie G Frederiksen |
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Provider Type | Practitioner - Obstetrics/gynecology |
Provider Identifiers | NPI Number: 1720015324 PECOS PAC ID: 2860474046 Enrollment ID: I20040602000683 |
Provider Name | Karen D Campbell |
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Provider Type | Practitioner - Nurse Practitioner |
Provider Identifiers | NPI Number: 1508889049 PECOS PAC ID: 4789607540 Enrollment ID: I20060106000463 |
Provider Name | Christopher R Dipersio |
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Provider Type | Practitioner - Podiatry |
Provider Identifiers | NPI Number: 1720050743 PECOS PAC ID: 8921997040 Enrollment ID: I20060123000300 |
Provider Name | James A Conrad |
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Provider Type | Practitioner - General Surgery |
Provider Identifiers | NPI Number: 1316983083 PECOS PAC ID: 6608879515 Enrollment ID: I20060815000310 |
Provider Name | Michael A Moll |
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Provider Type | Practitioner - Family Practice |
Provider Identifiers | NPI Number: 1609884881 PECOS PAC ID: 7113057209 Enrollment ID: I20100616000713 |
Provider Name | Lori S Moll |
---|---|
Provider Type | Practitioner - Family Practice |
Provider Identifiers | NPI Number: 1578572426 PECOS PAC ID: 8022148089 Enrollment ID: I20100617000640 |
Provider Name | Sandeep S Vijan |
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Provider Type | Practitioner - General Surgery |
Provider Identifiers | NPI Number: 1730220278 PECOS PAC ID: 4587755947 Enrollment ID: I20101115000469 |
Provider Name | Susan Kae Walker |
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Provider Type | Practitioner - Nurse Practitioner |
Provider Identifiers | NPI Number: 1972729192 PECOS PAC ID: 9739350745 Enrollment ID: I20110923000385 |
Provider Name | Regina J Griego |
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Provider Type | Practitioner - Nurse Practitioner |
Provider Identifiers | NPI Number: 1710274394 PECOS PAC ID: 0446422166 Enrollment ID: I20110930000298 |
Provider Name | Donald W Dutton |
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Provider Type | Practitioner - Family Practice |
Provider Identifiers | NPI Number: 1285929513 PECOS PAC ID: 3173745395 Enrollment ID: I20141103002413 |
Provider Name | Christopher J Stark |
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Provider Type | Practitioner - Hospitalist |
Provider Identifiers | NPI Number: 1013936764 PECOS PAC ID: 5991703381 Enrollment ID: I20170706002288 |
Provider Name | Erin Helbing |
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Provider Type | Practitioner - Nurse Practitioner |
Provider Identifiers | NPI Number: 1487182176 PECOS PAC ID: 2365718707 Enrollment ID: I20211007000315 |
Provider Name | Marilyn Doster |
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Provider Type | Practitioner - Nurse Practitioner |
Provider Identifiers | NPI Number: 1891484374 PECOS PAC ID: 0941666895 Enrollment ID: I20230518001223 |