MEDICARE: FRONT RANGE CLINIC INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	207QA0401X	Addiction Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1023604592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRONT RANGE CLINIC INC.

Provider Business Mailing Address
First Line	:	1120 E ELIZABETH ST STE G2
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-4044
Country	:	US
Telephone Number	:	970-493-9193
Fax Number	:

Provider Business Practice Location Address
First Line	:	7190 COLORADO BLVD STE 340
Second Line	:
City	:	COMMERCE CITY
State	:	CO
Zip	:	80022-1808
Country	:	US
Telephone Number	:	720-766-9172
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CLARK STEVEN MCCOY
Credential	:	MD
Telephone Number	:	970-493-9193

Provider Enumeration Date	:	12/17/2020
Last Update Date	:	12/17/2020

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