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General NPI Number Information
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NPI Number | 1881725844
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Entity Type | Organization
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Legal Business Name | INTERNAL MEDICINE CLINIC INC.
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Dates
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Enumeration Date | 03/08/2007
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Last Update Date | 12/04/2020
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Provider Practice Location Address
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Address Line | 2021 BATTLECREEK DR UNIT B
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City | FORT COLLINS
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State | CO
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Zip | 80528-5120
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Country | US
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Telephone | 970-224-9508
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Fax | 970-993-4289
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Provider Business Mailing Address
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Address Line | 2021 BATTLECREEK DR UNIT B
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City | FORT COLLINS
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State | CO
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Zip | 80528-5120
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Country | US
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Telephone | 970-224-9508
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Fax | 970-999-3428
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Authorized Official
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Title or Position | PRACTICE ADMIN
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Name | MRS. ALICIA D GOOSSENS
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Credential |
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Telephone | 970-224-9508
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 12-06712
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License Number State | CO
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