Healthcare Provider Details

I. General information

NPI: 1760816417
Provider Name (Legal Business Name): ELEVATION INTERNAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E 3RD ST
DELTA CO
81416-2815
US

IV. Provider business mailing address

PO BOX 1112
DURANGO CO
81302-1112
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-7681
  • Fax:
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDR0044007
License Number StateCO

VIII. Authorized Official

Name: LORI LABRECQUE
Title or Position: ACCTS MGR
Credential:
Phone: 702-453-3799