Healthcare Provider Details

I. General information

NPI: 1689186793
Provider Name (Legal Business Name): LISA ROVAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 E RAILROAD AVE
FORT MORGAN CO
80701-3365
US

IV. Provider business mailing address

211 W MAIN ST
STERLING CO
80751-3168
US

V. Phone/Fax

Practice location:
  • Phone: 970-867-4924
  • Fax: 970-867-2695
Mailing address:
  • Phone: 970-522-4549
  • Fax: 970-522-6898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: