Healthcare Provider Details

I. General information

NPI: 1780919712
Provider Name (Legal Business Name): PINE RIVER HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 WOLVERINE DR #2B
BAYFIELD CO
81122-9653
US

IV. Provider business mailing address

480 WOLVERINE DR #2B
BAYFIELD CO
81122-9653
US

V. Phone/Fax

Practice location:
  • Phone: 970-884-5173
  • Fax: 970-884-0123
Mailing address:
  • Phone: 970-884-5173
  • Fax: 970-884-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number174732
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number174732
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number174732
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number174732
License Number StateCO

VIII. Authorized Official

Name: MRS. NANCY BROOKER
Title or Position: OWNER, NURSE PRACTITIONER
Credential: CNP
Phone: 970-884-5173