Healthcare Provider Details

I. General information

NPI: 1730576844
Provider Name (Legal Business Name): FOUR CORNERS NATUROPATHIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 COUNTY ROAD 250 UNIT 7
DURANGO CO
81301-8848
US

IV. Provider business mailing address

545 E 31ST ST
DURANGO CO
81301-4335
US

V. Phone/Fax

Practice location:
  • Phone: 970-799-8961
  • Fax:
Mailing address:
  • Phone: 970-799-8961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0012355
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0171869
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number0000026
License Number StateCO

VIII. Authorized Official

Name: LAURA BOE
Title or Position: ND LPC RN
Credential: LPC
Phone: 970-799-8961