Healthcare Provider Details

I. General information

NPI: 1710972401
Provider Name (Legal Business Name): LYNNETTE C TELCK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 SOUTH 4TH STREET
KREMMLING CO
80459-0399
US

IV. Provider business mailing address

PO BOX 399 214 S. 4TH ST
KREMMLING CO
80459-0399
US

V. Phone/Fax

Practice location:
  • Phone: 970-724-3442
  • Fax: 970-724-9359
Mailing address:
  • Phone: 970-724-3442
  • Fax: 970-724-9359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number43652
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: