MEDICARE: ROCKY MOUNTAIN VEIN INSTITUTE PROFESSIONAL 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	2085R0204X	Vascular & Interventional Radiology Physician	45004	CO
2	261Q00000X	Clinic/Center
3	2085R0204X	Vascular & Interventional Radiology Physician

General Provider Information

NPI Number	:	1457685398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKY MOUNTAIN VEIN INSTITUTE PROFESSIONAL LLC

Provider Business Mailing Address
First Line	:	PO BOX 7702
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80537-0702
Country	:	US
Telephone Number	:	970-663-2742
Fax Number	:	970-342-2093

Provider Business Practice Location Address
First Line	:	115 E RIVERWALK UNIT 200
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-3320
Country	:	US
Telephone Number	:	719-543-8346
Fax Number	:	719-545-1829

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	DR. GORDON FABING GIBBS
Credential	:	MD
Telephone Number	:	719-543-8346

Provider Enumeration Date	:	09/24/2009
Last Update Date	:	01/11/2024

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