Healthcare Provider Details

I. General information

NPI: 1528510302
Provider Name (Legal Business Name): MOUNTAIN VIEW MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 TECH CENTER DR SUITE 106
COLORADO SPRINGS CO
80919-2353
US

IV. Provider business mailing address

5575 TECH CENTER DR SUITE 106
COLORADO SPRINGS CO
80919-2353
US

V. Phone/Fax

Practice location:
  • Phone: 719-590-1177
  • Fax:
Mailing address:
  • Phone: 719-590-1177
  • 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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRUCE MINEAR
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 719-590-1177