Healthcare Provider Details

I. General information

NPI: 1407953581
Provider Name (Legal Business Name): ST LUKES MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 OAKRIDGE DR SUITE B
FORT COLLINS CO
80525-5591
US

IV. Provider business mailing address

1101 OAKRIDGE DR SUITE B
FORT COLLINS CO
80525-5591
US

V. Phone/Fax

Practice location:
  • Phone: 970-223-1199
  • Fax: 970-223-9566
Mailing address:
  • Phone: 970-223-1199
  • Fax: 970-223-9566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number57743
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number24854
License Number StateCO

VIII. Authorized Official

Name: MICHAEL J LYNCH
Title or Position: OWNER
Credential: M.D.
Phone: 970-223-1199