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General NPI Number Information
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NPI Number | 1124795836
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Entity Type | Organization
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Legal Business Name | COUNTY LINE HEALTH CLINIC
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Dates
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Enumeration Date | 08/30/2021
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Last Update Date | 12/09/2021
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Provider Practice Location Address
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Address Line | 36053 US HIGHWAY 287
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City | WILEY
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State | CO
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Zip | 81092-9702
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Country | US
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Telephone | 719-688-9962
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Fax |
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Provider Business Mailing Address
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Address Line | 36053 US HIGHWAY 287
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City | WILEY
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State | CO
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Zip | 81092-9702
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHELBY CASPER
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Credential | MSN-FNP
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Telephone | 719-688-9962
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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