Provider Demographics
NPI:1144405739
Name:AGAPE FAMILY PRACTICE, P.C.
Entity Type:Organization
Organization Name:AGAPE FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SEVERANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-257-7116
Mailing Address - Street 1:2139 N 12TH ST
Mailing Address - Street 2:UNIT 4
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2901
Mailing Address - Country:US
Mailing Address - Phone:970-257-7116
Mailing Address - Fax:970-257-7119
Practice Address - Street 1:2139 N 12TH ST
Practice Address - Street 2:UNIT 4
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2901
Practice Address - Country:US
Practice Address - Phone:970-257-7116
Practice Address - Fax:970-257-7119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC382508Medicare PIN