Healthcare Provider Details

I. General information

NPI: 1598135451
Provider Name (Legal Business Name): FRONT RANGE CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2015
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 E ELIZABETH ST SUITE C
FORT COLLINS CO
80524-3951
US

IV. Provider business mailing address

1040 E ELIZABETH ST SUITE C
FORT COLLINS CO
80524-3951
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number0054001
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number0054001
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0054001
License Number StateCO

VIII. Authorized Official

Name: DR. CLARK MCCOY
Title or Position: PRESIDENT
Credential: MD
Phone: 352-214-7180