Provider Demographics
NPI:1609523299
Name:WELLNESS MOUNTAIN MEDICINE
Entity type:Organization
Organization Name:WELLNESS MOUNTAIN MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-401-0126
Mailing Address - Street 1:PO BOX 2134
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-2134
Mailing Address - Country:US
Mailing Address - Phone:970-401-0126
Mailing Address - Fax:
Practice Address - Street 1:615 FAIRHURST ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-4523
Practice Address - Country:US
Practice Address - Phone:970-522-0122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-03
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty