Provider Demographics
NPI:1275591281
Name:FORT COLLINS WOMEN'S CLINIC, PC
Entity Type:Organization
Organization Name:FORT COLLINS WOMEN'S CLINIC, PC
Other - Org Name:THE WOMEN'S CLINIC OF NORTHERN COLORADO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KENYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-493-7442
Mailing Address - Street 1:1107 S LEMAY AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3955
Mailing Address - Country:US
Mailing Address - Phone:970-493-7442
Mailing Address - Fax:970-493-2990
Practice Address - Street 1:1107 S LEMAY AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3957
Practice Address - Country:US
Practice Address - Phone:970-493-7442
Practice Address - Fax:970-493-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04010625Medicaid
COC84008Medicare PIN