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General NPI Number Information
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NPI Number | 1225854425
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Entity Type | Organization
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Legal Business Name | FOUR MILE CREEK HEALTH
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Dates
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Enumeration Date | 12/03/2024
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Last Update Date | 12/03/2024
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Provider Practice Location Address
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Address Line | 3434 47TH ST STE 225
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City | BOULDER
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State | CO
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Zip | 80301-1880
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Country | US
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Telephone | 703-850-1533
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Fax | 303-586-7592
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Provider Business Mailing Address
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Address Line | 3434 47TH ST STE 225
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City | BOULDER
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State | CO
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Zip | 80301-1880
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Country | US
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Telephone | 703-850-1533
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | RADFORD FAGAN
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Credential |
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Telephone | 720-792-2852
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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