Healthcare Provider Details

I. General information

NPI: 1255763710
Provider Name (Legal Business Name): ARKANSAS VALLEY FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 10/08/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 SAN JUAN AVE
LA JUNTA CO
81050-3340
US

IV. Provider business mailing address

2317 SAN JUAN AVE
LA JUNTA CO
81050-3340
US

V. Phone/Fax

Practice location:
  • Phone: 719-383-2325
  • Fax: 719-383-2327
Mailing address:
  • Phone: 719-383-2325
  • Fax: 719-383-2327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31834
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: RICHARD KENT BOOK
Title or Position: OWNER/PROVIDER
Credential:
Phone: 719-383-2325