Healthcare Provider Details

I. General information

NPI: 1982270138
Provider Name (Legal Business Name): COLORADO MOUNTAIN MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 W MAIN ST STE 101
FRISCO CO
80443-5966
US

IV. Provider business mailing address

PO BOX 4330
AVON CO
81620-4330
US

V. Phone/Fax

Practice location:
  • Phone: 970-926-6340
  • Fax:
Mailing address:
  • Phone: 970-926-6340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LISA KERSTIENS
Title or Position: PHYSICIAN RELATIONS MANAGER
Credential:
Phone: 970-845-2903