Provider Demographics
NPI:1497155089
Name:THOMPSON RIVER PEDIATRICS AND URGENT CARE, LLC
Entity Type:Organization
Organization Name:THOMPSON RIVER PEDIATRICS AND URGENT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-619-8139
Mailing Address - Street 1:4435 RONALD REAGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-6566
Mailing Address - Country:US
Mailing Address - Phone:970-619-8139
Mailing Address - Fax:970-612-8013
Practice Address - Street 1:4435 RONALD REAGAN BLVD.
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-6409
Practice Address - Country:US
Practice Address - Phone:970-619-8139
Practice Address - Fax:970-612-8013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0054205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76000265Medicaid