Healthcare Provider Details

I. General information

NPI: 1407848518
Provider Name (Legal Business Name): REBECCA ANN DE LATORRE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 E ELIZABETH ST
FORT COLLINS CO
80524-4007
US

IV. Provider business mailing address

1006 FOX HILLS DR
FORT COLLINS CO
80526-3905
US

V. Phone/Fax

Practice location:
  • Phone: 970-482-2791
  • Fax: 970-495-9843
Mailing address:
  • Phone: 970-223-7732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32165
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: