Provider Demographics
NPI:1417444043
Name:PREMIER RURAL FAMILY MEDICAL & DENTAL CARE, LLC
Entity Type:Organization
Organization Name:PREMIER RURAL FAMILY MEDICAL & DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-634-5700
Mailing Address - Street 1:24 S WEBER ST STE 400
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1928
Mailing Address - Country:US
Mailing Address - Phone:719-634-5700
Mailing Address - Fax:719-633-8477
Practice Address - Street 1:1101 TELLER COUNTY ROAD 1
Practice Address - Street 2:
Practice Address - City:CRIPPLE CREEK
Practice Address - State:CO
Practice Address - Zip Code:80813
Practice Address - Country:US
Practice Address - Phone:419-508-7686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty