Healthcare Provider Details

I. General information

NPI: 1982864757
Provider Name (Legal Business Name): MOUNTAIN PEACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2008
Last Update Date: 06/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCADO ST SUITE 205
DURANGO CO
81301-7300
US

IV. Provider business mailing address

1 MERCADO ST SUITE 205
DURANGO CO
81301-7300
US

V. Phone/Fax

Practice location:
  • Phone: 970-385-7295
  • Fax: 970-385-7299
Mailing address:
  • Phone: 970-385-7295
  • Fax: 970-385-7299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number46157
License Number StateCO

VIII. Authorized Official

Name: DR. SUSAN C RISTOW
Title or Position: PRESIDENT
Credential: M.D.
Phone: 970-385-7295