Healthcare Provider Details

I. General information

NPI: 1720301344
Provider Name (Legal Business Name): YOUR FAMILY MEDICAL HOME,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 08/17/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N PARK AV SUITE 2A
BRECKENRIDGE CO
80424
US

IV. Provider business mailing address

PO BOX 5620
BRECKENRIDGE CO
80424-5620
US

V. Phone/Fax

Practice location:
  • Phone: 970-238-7070
  • Fax: 970-453-5332
Mailing address:
  • Phone: 970-238-7070
  • Fax: 970-423-5332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31975
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN DAVID ZAITZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 925-597-0121