Healthcare Provider Details

I. General information

NPI: 1669535118
Provider Name (Legal Business Name): HERITAGE FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 ROBERTSON ST
FORT COLLINS CO
80524
US

IV. Provider business mailing address

1006 ROBERTSON ST
FORT COLLINS CO
80524
US

V. Phone/Fax

Practice location:
  • Phone: 970-224-1596
  • Fax: 970-530-1919
Mailing address:
  • Phone: 970-224-1596
  • Fax: 970-530-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36358
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SCOTT TALBOT
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 970-224-1596