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General NPI Number Information
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NPI Number | 1124474945
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Entity Type | Organization
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Legal Business Name | TRAVERSE BAY MEDICAL, PC
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Dates
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Enumeration Date | 05/11/2016
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Last Update Date | 08/01/2016
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Provider Practice Location Address
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Address Line | 1815 SUNSHINE AVE
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City | LONGMONT
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State | CO
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Zip | 80504-2225
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Country | US
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Telephone | 303-722-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 2575 PARK LN STE 101-B
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City | LAFAYETTE
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State | CO
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Zip | 80026-3200
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Country | US
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Telephone | 303-722-9000
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Fax | 844-800-1478
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARY LOUISE LOUDER
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Credential | D.O
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Telephone | 303-722-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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