Healthcare Provider Details

I. General information

NPI: 1104342443
Provider Name (Legal Business Name): FRONT RANGE CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 VIVIAN ST
LONGMONT CO
80501-3217
US

IV. Provider business mailing address

1040 E ELIZABETH ST STE C
FORT COLLINS CO
80524-3952
US

V. Phone/Fax

Practice location:
  • Phone: 303-834-8809
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0054001
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number0054001
License Number StateCO

VIII. Authorized Official

Name: DR. CLARK MCCOY
Title or Position: PRESIDENT
Credential: MD
Phone: 352-214-7180