Provider Demographics
NPI:1235238866
Name:FAMILY PRACTICE CLINIC, PC
Entity Type:Organization
Organization Name:FAMILY PRACTICE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:VIRGIL
Authorized Official - Last Name:LINDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-867-8221
Mailing Address - Street 1:220 E BEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-3103
Mailing Address - Country:US
Mailing Address - Phone:970-867-8221
Mailing Address - Fax:970-867-7124
Practice Address - Street 1:220 E BEAVER AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3103
Practice Address - Country:US
Practice Address - Phone:970-867-8221
Practice Address - Fax:970-867-7124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01247196Medicaid
CO01247196Medicaid
COD24501Medicare UPIN