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General NPI Number Information
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NPI Number | 1740706035
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Entity Type | Organization
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Legal Business Name | FRONT RANGE CLINIC INC.
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Dates
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Enumeration Date | 08/17/2017
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Last Update Date | 12/17/2020
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Provider Practice Location Address
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Address Line | 11172 HURON ST STE 20
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City | NORTHGLENN
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State | CO
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Zip | 80234-4380
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Country | US
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Telephone | 303-568-9694
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Fax |
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Provider Business Mailing Address
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Address Line | 1040 E ELIZABETH ST STE C
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City | FORT COLLINS
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State | CO
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Zip | 80524-3952
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Country | US
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Telephone | 352-214-7180
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CLARK MCCOY
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Credential | MD
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Telephone | 352-214-7180
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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 | 0054001
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | 0054001
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License Number State | CO
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