Healthcare Provider Details

I. General information

NPI: 1356374300
Provider Name (Legal Business Name): SALIDA FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E 1ST ST
SALIDA CO
81201
US

IV. Provider business mailing address

320 E 1ST ST
SALIDA CO
81201-2802
US

V. Phone/Fax

Practice location:
  • Phone: 719-539-3612
  • Fax: 719-539-3028
Mailing address:
  • Phone: 719-539-3612
  • Fax: 719-539-3028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TRUDY L FOGG
Title or Position: PRACTICE ADMINISTATOR
Credential:
Phone: 719-539-3583