Healthcare Provider Details

I. General information

NPI: 1235274036
Provider Name (Legal Business Name): ENT CLINIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 LUKE ST
FORT COLLINS CO
80524-4037
US

IV. Provider business mailing address

1032 LUKE ST
FORT COLLINS CO
80524-4037
US

V. Phone/Fax

Practice location:
  • Phone: 970-484-8686
  • Fax: 970-484-1064
Mailing address:
  • Phone: 970-484-8686
  • Fax: 970-484-1064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA CONLON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 970-484-8686