Healthcare Provider Details

I. General information

NPI: 1235310285
Provider Name (Legal Business Name): STONEY MESA FAMILY PRACTICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 HILLCREST DR
DELTA CO
81416-2810
US

IV. Provider business mailing address

PO BOX 1129
DELTA CO
81416-1129
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-5061
  • Fax: 970-874-5074
Mailing address:
  • Phone: 970-874-2470
  • Fax: 970-874-2475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39111
License Number StateCO

VIII. Authorized Official

Name: MICHELLE PURVIS
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 970-874-5061