Provider Demographics
NPI:1235274036
Name:ENT CLINIC P.C.
Entity Type:Organization
Organization Name:ENT CLINIC P.C.
Other - Org Name:ALPHA ENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-484-8686
Mailing Address - Street 1:1032 LUKE ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4037
Mailing Address - Country:US
Mailing Address - Phone:970-484-8686
Mailing Address - Fax:970-484-1064
Practice Address - Street 1:1032 LUKE ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4037
Practice Address - Country:US
Practice Address - Phone:970-484-8686
Practice Address - Fax:970-484-1064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04008512Medicaid
COC392408Medicare PIN