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General NPI Number Information
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NPI Number | 1962366179
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Entity Type | Organization
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Legal Business Name | POUDRE VALLEY MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 12/11/2025
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Last Update Date | 12/11/2025
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Provider Practice Location Address
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Address Line | 1330 OAKRIDGE DR UNIT 100
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City | FORT COLLINS
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State | CO
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Zip | 80525-9651
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Country | US
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Telephone | 970-207-4864
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Fax |
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Provider Business Mailing Address
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Address Line | 2695 ROCKY MOUNTAIN AVE STE 150
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City | LOVELAND
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State | CO
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Zip | 80538-9071
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF CREDENTIALING
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Name | JANA CONROY
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Credential |
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Telephone | 970-207-4864
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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