Provider Demographics
NPI:1083650527
Name:COLOR COUNTRY PEDIATRICS, LLC
Entity Type:Organization
Organization Name:COLOR COUNTRY PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURROWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-865-0218
Mailing Address - Street 1:PO BOX 3040
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-3040
Mailing Address - Country:US
Mailing Address - Phone:435-865-0218
Mailing Address - Fax:435-865-0228
Practice Address - Street 1:1333 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-9113
Practice Address - Country:US
Practice Address - Phone:435-865-0218
Practice Address - Fax:435-865-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000058040Medicare PIN