Healthcare Provider Details

I. General information

NPI: 1194909804
Provider Name (Legal Business Name): DEBORAH GREEN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 PARK AVE
FORT LUPTON CO
80621-1929
US

IV. Provider business mailing address

315 PARK AVE
FORT LUPTON CO
80621-1929
US

V. Phone/Fax

Practice location:
  • Phone: 303-857-6111
  • Fax: 303-857-2459
Mailing address:
  • Phone: 303-857-6111
  • Fax: 303-857-2459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number241330
License Number StateCO

VIII. Authorized Official

Name: NANCY SALAS
Title or Position: OWNER
Credential: MD PC
Phone: 303-857-6111