Healthcare Provider Details

I. General information

NPI: 1023773611
Provider Name (Legal Business Name): DESERT RIVER FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 PHAY AVE STE A
CANON CITY CO
81212-2349
US

IV. Provider business mailing address

1335 PHAY AVE STE A
CANON CITY CO
81212-2349
US

V. Phone/Fax

Practice location:
  • Phone: 719-285-8890
  • Fax:
Mailing address:
  • Phone: 719-285-8890
  • 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 Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TARA L ROBICHEAUX
Title or Position: BUSINESS MANAGER
Credential:
Phone: 719-285-8890