MEDICARE: ROCKY MOUNTAIN CLINICS 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	207Q00000X	Family Medicine Physician
2	207QA0401X	Addiction Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1639895568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKY MOUNTAIN CLINICS LLC

Provider Business Mailing Address
First Line	:	1120 E ELIZABETH ST STE G2
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-4044
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1861 AUSTIN BLUFFS PKWY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-7868
Country	:	US
Telephone Number	:	719-419-7735
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	SABRINA GIBSON
Credential	:
Telephone Number	:	970-493-9193

Provider Enumeration Date	:	10/12/2022
Last Update Date	:	03/14/2023

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