Provider Demographics
NPI:1356474647
Name:OUR LADY OF GRACE MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:OUR LADY OF GRACE MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:F
Authorized Official - Last Name:VERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-531-5181
Mailing Address - Street 1:PO BOX 350968
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80035-0968
Mailing Address - Country:US
Mailing Address - Phone:303-531-5181
Mailing Address - Fax:303-531-5185
Practice Address - Street 1:992 W 104TH AVE
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-3801
Practice Address - Country:US
Practice Address - Phone:303-531-5181
Practice Address - Fax:303-531-5185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92600786Medicaid
CO92600786Medicaid