Healthcare Provider Details

I. General information

NPI: 1679608137
Provider Name (Legal Business Name): MOUNTAIN FAMILY LIVING, A PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 N CORA, STE 2
RIDGWAY CO
81432
US

IV. Provider business mailing address

160 N CORA, STE 2 PO BOX 698
RIDGWAY CO
81432
US

V. Phone/Fax

Practice location:
  • Phone: 970-626-4202
  • Fax:
Mailing address:
  • Phone: 970-626-4202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLMFT193
License Number StateCO

VIII. Authorized Official

Name: RANDOLPH - STANKO
Title or Position: PRESIDENT
Credential: LMFT
Phone: 970-626-4202