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	207QA0401X	Addiction Medicine (Family Medicine) Physician	0054001	CO
2	207QB0002X	Obesity Medicine (Family Medicine) Physician	0054001	CO
3	207Q00000X	Family Medicine Physician	0054001	CO

General Provider Information

NPI Number	:	1598135451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRONT RANGE CLINIC INC.

Provider Business Mailing Address
First Line	:	1040 E ELIZABETH ST
Second Line	:	SUITE C
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3951
Country	:	US
Telephone Number	:	970-493-9193
Fax Number	:

Provider Business Practice Location Address
First Line	:	1040 E ELIZABETH ST
Second Line	:	SUITE C
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3951
Country	:	US
Telephone Number	:	970-493-9193
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CLARK MCCOY
Credential	:	MD
Telephone Number	:	352-214-7180

Provider Enumeration Date	:	10/04/2015
Last Update Date	:	01/12/2021

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