Provider Demographics
NPI:1326726704
Name:FORT LEWIS COLLEGE
Entity Type:Organization
Organization Name:FORT LEWIS COLLEGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:KLOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:970-247-7355
Mailing Address - Street 1:1000 RIM DR # 170
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-3908
Mailing Address - Country:US
Mailing Address - Phone:970-217-7355
Mailing Address - Fax:970-247-7621
Practice Address - Street 1:1000 RIM DR # 170
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-3908
Practice Address - Country:US
Practice Address - Phone:970-247-7355
Practice Address - Fax:970-247-7621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-06
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health