Provider Demographics
NPI:1194844688
Name:DESERT SUN MEDICAL CENTER, P.C.
Entity Type:Organization
Organization Name:DESERT SUN MEDICAL CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:FRYBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-434-8570
Mailing Address - Street 1:573 32 RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:CO
Mailing Address - Zip Code:81520-7624
Mailing Address - Country:US
Mailing Address - Phone:970-434-8570
Mailing Address - Fax:
Practice Address - Street 1:1212 BOOKCLIFF AVE STE 3
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8161
Practice Address - Country:US
Practice Address - Phone:970-434-8570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04006359Medicaid
CO1194844688Medicaid