Healthcare Provider Details

I. General information

NPI: 1629843362
Provider Name (Legal Business Name): HEARTLIGHT FAMILY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2023
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 S POTOMAC ST STE 300
AURORA CO
80012-4512
US

IV. Provider business mailing address

1421 S POTOMAC ST STE 140
AURORA CO
80012-4535
US

V. Phone/Fax

Practice location:
  • Phone: 204-853-1787
  • Fax:
Mailing address:
  • Phone: 204-853-1787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRENT HERRON
Title or Position: OWNER
Credential:
Phone: 303-249-0908