Healthcare Provider Details

I. General information

NPI: 1942260377
Provider Name (Legal Business Name): FOUR CORNERS HEART CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E 3RD AVE SUITE112
DURANGO CO
81301-5016
US

IV. Provider business mailing address

1800 E 3RD AVE SUITE 112
DURANGO CO
81301-5016
US

V. Phone/Fax

Practice location:
  • Phone: 970-247-1120
  • Fax: 970-247-1128
Mailing address:
  • Phone: 970-247-1120
  • Fax: 970-247-1128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: ANN LAU
Title or Position: DIRECTOR OF ACCOUNTS RECEIVABLE
Credential:
Phone: 303-295-8737