MEDICARE: THE HEALTHCARE CLINIC OF FORT COLLINS

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	305S00000X	Point of Service	184924	CO

General Provider Information

NPI Number	:	1912287640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE HEALTHCARE CLINIC OF FORT COLLINS

Provider Business Mailing Address
First Line	:	24667 SLATER MILL RD
Second Line	:
City	:	DAPHNE
State	:	AL
Zip	:	36526-0199
Country	:	US
Telephone Number	:	970-452-7404
Fax Number	:

Provider Business Practice Location Address
First Line	:	1721 W HARMONY ROAD
Second Line	:	SUITE 102
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-7611
Country	:	US
Telephone Number	:	970-223-1999
Fax Number	:	970-223-4419

Authorized Official
Title or Position	:	OWNER
Name	:	LISA W MYERS
Credential	:	APNP
Telephone Number	:	970-452-7404

Provider Enumeration Date	:	08/25/2011
Last Update Date	:	06/28/2021

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