Provider Demographics
NPI:1235732058
Name:POUDRE VALLEY MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:POUDRE VALLEY MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-364-9560
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11605 MERIDIAN MARKET VW STE 184
Practice Address - Street 2:
Practice Address - City:FALCON
Practice Address - State:CO
Practice Address - Zip Code:80831-8238
Practice Address - Country:US
Practice Address - Phone:719-364-9560
Practice Address - Fax:719-364-7680
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POUDRE VALLEY MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-17
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty