Healthcare Provider Details

I. General information

NPI: 1699777912
Provider Name (Legal Business Name): MOUNTIAN MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 ELK AVENUE
CRESTED BUTTE CO
81423
US

IV. Provider business mailing address

PO BOX 122
CRESTED BUTTE CO
81224-0122
US

V. Phone/Fax

Practice location:
  • Phone: 970-349-1046
  • Fax: 970-349-1051
Mailing address:
  • Phone: 970-349-1046
  • Fax: 970-349-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number512338
License Number StateCO

VIII. Authorized Official

Name: DR. LEANDRA LYNCH
Title or Position: DIRECTOR/OFFICER
Credential: MD
Phone: 970-349-1046