Healthcare Provider Details

I. General information

NPI: 1326648254
Provider Name (Legal Business Name): SURFACE CREEK FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 SW 8TH AVE
CEDAREDGE CO
81413
US

IV. Provider business mailing address

255 SW 8TH AVE
CEDAREDGE CO
81413
US

V. Phone/Fax

Practice location:
  • Phone: 970-856-3146
  • Fax: 970-806-4385
Mailing address:
  • Phone: 970-856-3146
  • Fax: 970-806-4385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN L PULSIPHER
Title or Position: PRESIDENT
Credential: D.O
Phone: 970-856-3146