Provider Demographics
NPI:1336455997
Name:LITTLE POUDRE FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:LITTLE POUDRE FAMILY CLINIC, LLC
Other - Org Name:LITTLE POUDRE FAMILY CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCGRAW
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:970-472-2001
Mailing Address - Street 1:3817 W COUNTY ROAD 54G
Mailing Address - Street 2:
Mailing Address - City:LAPORTE
Mailing Address - State:CO
Mailing Address - Zip Code:80535-9360
Mailing Address - Country:US
Mailing Address - Phone:970-472-2001
Mailing Address - Fax:970-212-9336
Practice Address - Street 1:3817 W COUNTY ROAD 54G
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:CO
Practice Address - Zip Code:80535-9360
Practice Address - Country:US
Practice Address - Phone:970-472-2001
Practice Address - Fax:970-212-9336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46455361Medicaid