MEDICARE: LIFESTYLE MEDICINE AT MIRAMONT, LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1043513724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESTYLE MEDICINE AT MIRAMONT, LLC

Provider Business Mailing Address
First Line	:	2211 S COLLEGE AVE
Second Line	:	UNIT 300
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-1489
Country	:	US
Telephone Number	:	970-237-6339
Fax Number	:	970-482-2091

Provider Business Practice Location Address
First Line	:	2211 S COLLEGE AVE
Second Line	:	UNIT 300
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-1489
Country	:	US
Telephone Number	:	970-237-6339
Fax Number	:	970-482-2091

Authorized Official
Title or Position	:	VICE PRESIDENT OF OPERATIONS
Name	:	MS. LISA AUSTIN
Credential	:
Telephone Number	:	970-237-6339

Provider Enumeration Date	:	12/17/2010
Last Update Date	:	03/25/2011

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