Provider Demographics
NPI:1235292293
Name:MOUNTAIN FAMILY HEALTH CENTERS
Entity Type:Organization
Organization Name:MOUNTAIN FAMILY HEALTH CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-945-2840
Mailing Address - Street 1:1905 BLAKE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4288
Mailing Address - Country:US
Mailing Address - Phone:970-945-2840
Mailing Address - Fax:970-945-2893
Practice Address - Street 1:562 GREGORY STREET
Practice Address - Street 2:
Practice Address - City:BLACK HAWK
Practice Address - State:CO
Practice Address - Zip Code:80422
Practice Address - Country:US
Practice Address - Phone:303-582-5276
Practice Address - Fax:303-582-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0040261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05600812Medicaid
CO061912Medicare PIN
COC12704Medicare Oscar/Certification