Healthcare Provider Details

I. General information

NPI: 1396794046
Provider Name (Legal Business Name): LARRY WAYNE KIPE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 RUSSELL ST
CRAIG CO
81625-2018
US

IV. Provider business mailing address

600 RUSSELL ST
CRAIG CO
81625-2018
US

V. Phone/Fax

Practice location:
  • Phone: 970-824-3252
  • Fax: 970-824-8015
Mailing address:
  • Phone: 970-824-3252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number28686
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR0028686
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: