MEDICARE: FORT COLLINS YOUTH CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1043807209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT COLLINS YOUTH CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 7328
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80537-0328
Country	:	US
Telephone Number	:	970-663-2742
Fax Number	:	970-342-2093

Provider Business Practice Location Address
First Line	:	4845 WEITZEL ST
Second Line	:
City	:	TIMNATH
State	:	CO
Zip	:	80547-4800
Country	:	US
Telephone Number	:	970-267-9510
Fax Number	:	970-207-9967

Authorized Official
Title or Position	:	EXECUTIVE ASSISTANT
Name	:	STEPHANIE FRED
Credential	:
Telephone Number	:	970-267-9510

Provider Enumeration Date	:	12/22/2020
Last Update Date	:	12/22/2020

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Directions to “FORT COLLINS YOUTH CLINIC ” Practice Location

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