Provider Demographics
NPI:1407012826
Name:HERON LAKE LLC
Entity Type:Organization
Organization Name:HERON LAKE LLC
Other - Org Name:FOXTRAIL FAMILY MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-237-7003
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1625 FOXTRAIL DR
Practice Address - Street 2:STE 190
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9088
Practice Address - Country:US
Practice Address - Phone:970-619-6900
Practice Address - Fax:970-619-6990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERON LAKE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-05
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92181031Medicaid
COCOB4480Medicare PIN