Healthcare Provider Details

I. General information

NPI: 1477565380
Provider Name (Legal Business Name): LONGS PEAK FAMILY PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 SUNSET ST
LONGMONT CO
80501-3215
US

IV. Provider business mailing address

1309 SUNSET ST
LONGMONT CO
80501-3215
US

V. Phone/Fax

Practice location:
  • Phone: 303-772-5578
  • Fax: 303-772-8207
Mailing address:
  • Phone: 303-772-5578
  • Fax: 303-772-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN I ROACH
Title or Position: OFFICER
Credential: M.D.
Phone: 303-772-5578