Healthcare Provider Details

I. General information

NPI: 1124795836
Provider Name (Legal Business Name): COUNTY LINE HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36053 US HIGHWAY 287
WILEY CO
81092-9702
US

IV. Provider business mailing address

36053 US HIGHWAY 287
WILEY CO
81092-9702
US

V. Phone/Fax

Practice location:
  • Phone: 719-688-9962
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHELBY CASPER
Title or Position: OWNER
Credential: MSN-FNP
Phone: 719-688-9962