Provider Demographics
NPI:1376602581
Name:HEALING GARDENS HEALTH CENTER
Entity Type:Organization
Organization Name:HEALING GARDENS HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-472-6789
Mailing Address - Street 1:315 CANYON AVENUE
Mailing Address - Street 2:SUITE1
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2677
Mailing Address - Country:US
Mailing Address - Phone:970-472-6789
Mailing Address - Fax:970-472-6799
Practice Address - Street 1:315 CANYON AVE
Practice Address - Street 2:SUITE1
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2677
Practice Address - Country:US
Practice Address - Phone:970-472-6789
Practice Address - Fax:970-472-6799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79850731Medicaid
COF86554Medicare UPIN
CO79850731Medicaid