=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477833044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LOVELAND YOUTH CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2011
-----------------------------------------------------
Last Update Date | 08/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2021 BOISE AVE
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-5037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-669-3298
-----------------------------------------------------
Fax | 970-669-6244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2021 BOISE AVE
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-5037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-669-3298
-----------------------------------------------------
Fax | 970-669-6244
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | DR. MICHAEL QUINTANA
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 970-669-3298
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------