MEDICARE: POUDRE VALLEY MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	225X00000X	Occupational Therapist
2	1041C0700X	Clinical Social Worker
3	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1124900998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POUDRE VALLEY MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	2695 ROCKY MOUNTAIN AVE STE 150
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-9071
Country	:	US
Telephone Number	:	970-624-4443
Fax Number	:

Provider Business Practice Location Address
First Line	:	1107 S LEMAY AVE STE 100
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3956
Country	:	US
Telephone Number	:	970-495-8440
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR CREDENTIALING
Name	:	JANA CONROY
Credential	:
Telephone Number	:	970-624-4443

Provider Enumeration Date	:	07/23/2025
Last Update Date	:	11/25/2025

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