Healthcare Provider Details

I. General information

NPI: 1407012826
Provider Name (Legal Business Name): HERON LAKE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 FOXTRAIL DR STE 190
LOVELAND CO
80538-9088
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-8702
US

V. Phone/Fax

Practice location:
  • Phone: 970-619-6900
  • Fax: 970-619-6990
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE DOUGHTY
Title or Position: CFO
Credential:
Phone: 970-237-7003