Provider Demographics
NPI:1043513724
Name:LIFESTYLE MEDICINE AT MIRAMONT, LLC
Entity type:Organization
Organization Name:LIFESTYLE MEDICINE AT MIRAMONT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-237-6339
Mailing Address - Street 1:2211 S COLLEGE AVE
Mailing Address - Street 2:UNIT 300
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1489
Mailing Address - Country:US
Mailing Address - Phone:970-237-6339
Mailing Address - Fax:970-482-2091
Practice Address - Street 1:2211 S COLLEGE AVE
Practice Address - Street 2:UNIT 300
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1489
Practice Address - Country:US
Practice Address - Phone:970-237-6339
Practice Address - Fax:970-482-2091
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:URGENT CARE AT MIRAMONT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-17
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care