Provider Demographics
NPI:1023562030
Name:PVHS-ICM HEALTH AND WELLNESS, LLC
Entity Type:Organization
Organization Name:PVHS-ICM HEALTH AND WELLNESS, LLC
Other - Org Name:WOODWARD
Other - Org Type:Other Name
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:SPROWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-495-6201
Mailing Address - Street 1:3702 AUTOMATION WAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5737
Mailing Address - Country:US
Mailing Address - Phone:970-495-6201
Mailing Address - Fax:
Practice Address - Street 1:3702 AUTOMATION WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5737
Practice Address - Country:US
Practice Address - Phone:970-495-6201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center