MEDICARE: POUDRE VALLEY RADIATION ONCOLOGY 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	2085R0001X	Radiation Oncology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538137955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POUDRE VALLEY RADIATION ONCOLOGY LLC

Provider Business Mailing Address
First Line	:	PO BOX 211367
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80221-0392
Country	:	US
Telephone Number	:	303-427-0648
Fax Number	:	303-427-0433

Provider Business Practice Location Address
First Line	:	2121 EAST HARMONY ROAD
Second Line	:	SUITE 160
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-0403
Country	:	US
Telephone Number	:	970-482-3328
Fax Number	:	970-482-1433

Authorized Official
Title or Position	:	BUSINESS ADMINISTRATOR
Name	:	MRS. GLENDA ORR
Credential	:
Telephone Number	:	303-427-0648

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	10/16/2007

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