Healthcare Provider Details

I. General information

NPI: 1417444043
Provider Name (Legal Business Name): PREMIER RURAL FAMILY MEDICAL & DENTAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 TELLER COUNTY ROAD 1
CRIPPLE CREEK CO
80813
US

IV. Provider business mailing address

24 S WEBER ST STE 400
COLORADO SPRINGS CO
80903-1928
US

V. Phone/Fax

Practice location:
  • Phone: 419-508-7686
  • Fax:
Mailing address:
  • Phone: 719-634-5700
  • Fax: 719-633-8477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM J ROBERS
Title or Position: ATTORNEY
Credential:
Phone: 719-634-5700