Provider Demographics
NPI:1265486930
Name:PHC-FORT MORGAN INC
Entity Type:Organization
Organization Name:PHC-FORT MORGAN INC
Other - Org Name:COLORADO PLAINS CLINIC - WIGGINS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:103 POWELL CT
Mailing Address - Street 2:STE. 200
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5079
Mailing Address - Country:US
Mailing Address - Phone:615-372-8500
Mailing Address - Fax:615-372-8572
Practice Address - Street 1:226 MAIN ST
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:CO
Practice Address - Zip Code:80654-1368
Practice Address - Country:US
Practice Address - Phone:970-483-7283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHC-FORT MORGAN INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
068505Medicare ID - Type UnspecifiedRHC