Healthcare Provider Details

I. General information

NPI: 1831694231
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES PROF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 COTTONWOOD ST STE 101
DELTA CO
81416-4404
US

IV. Provider business mailing address

947 S 5TH ST
MONTROSE CO
81401-5716
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-7552
  • Fax: 970-874-7554
Mailing address:
  • Phone: 970-249-2421
  • Fax: 970-249-1203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: AMBER HICKERT
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 970-249-2421