Healthcare Provider Details

I. General information

NPI: 1053519868
Provider Name (Legal Business Name): SOUTH LOGAN FAMILY PRACTICE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 S LOGAN ST
DENVER CO
80209-4197
US

IV. Provider business mailing address

895 S LOGAN ST
DENVER CO
80209-4197
US

V. Phone/Fax

Practice location:
  • Phone: 303-733-3764
  • Fax: 303-733-0868
Mailing address:
  • Phone: 303-733-3764
  • Fax: 303-733-0868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26202
License Number StateCO

VIII. Authorized Official

Name: VICKI LAWS
Title or Position: OFFICE MANAGER
Credential:
Phone: 303-733-3764