Healthcare Provider Details

I. General information

NPI: 1467963447
Provider Name (Legal Business Name): FRONT RANGE CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 E ELIZABETH ST STE C
FORT COLLINS CO
80524-3952
US

IV. Provider business mailing address

1040 E ELIZABETH ST STE C
FORT COLLINS CO
80524-3952
US

V. Phone/Fax

Practice location:
  • Phone: 970-493-9193
  • Fax: 970-639-4475
Mailing address:
  • Phone: 970-493-9193
  • Fax: 970-639-4475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. CLARK STEVEN MCCOY
Title or Position: PRESIDENT
Credential: MD
Phone: 970-493-9193