Provider Demographics
NPI:1255865713
Name:IDEAL FAMILY MEDICINE, LTD
Entity Type:Organization
Organization Name:IDEAL FAMILY MEDICINE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JADE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:719-582-1489
Mailing Address - Street 1:19 E ABARR DR # 200
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81007-5436
Mailing Address - Country:US
Mailing Address - Phone:719-582-1489
Mailing Address - Fax:719-434-9807
Practice Address - Street 1:1910 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3322
Practice Address - Country:US
Practice Address - Phone:719-582-1489
Practice Address - Fax:719-434-9807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0992962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1154861995Medicaid