Healthcare Provider Details

I. General information

NPI: 1316120991
Provider Name (Legal Business Name): NEPHROLOGY CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 WILLET DR
LARAMIE WY
82072
US

IV. Provider business mailing address

1600 SPECHT POINT RD SUITE 127
FT COLLINS CO
80525-4311
US

V. Phone/Fax

Practice location:
  • Phone: 970-493-7733
  • Fax: 970-493-8745
Mailing address:
  • Phone: 970-493-7733
  • Fax: 970-493-8745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: TOBEY MIKULA
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 970-493-7733