Healthcare Provider Details

I. General information

NPI: 1578746871
Provider Name (Legal Business Name): ROARING FORK DERMATOLOGY INC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23262 TWO RIVERS RD
BASALT CO
81621-9227
US

IV. Provider business mailing address

PO BOX 1489
BASALT CO
81621-1489
US

V. Phone/Fax

Practice location:
  • Phone: 970-927-4731
  • Fax: 970-927-4420
Mailing address:
  • Phone: 970-927-4731
  • Fax: 970-927-4420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JULIAN RAMSEY MELLETTE JR.
Title or Position: OWNER
Credential: MD
Phone: 970-927-4731