=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902804032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEDAR POINT HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2005
-----------------------------------------------------
Last Update Date | 08/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3330 S RIO GRANDE AVE STE 300
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81401-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-249-7751
-----------------------------------------------------
Fax | 970-249-5029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2303 S TOWNSEND AVE
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81401-5452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-249-7751
-----------------------------------------------------
Fax | 970-249-5029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | MR. CORY PHILLIPS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-249-7751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------