Provider Demographics
NPI:1538137955
Name:POUDRE VALLEY RADIATION ONCOLOGY LLC
Entity Type:Organization
Organization Name:POUDRE VALLEY RADIATION ONCOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-427-0648
Mailing Address - Street 1:PO BOX 211367
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80221-0392
Mailing Address - Country:US
Mailing Address - Phone:303-427-0648
Mailing Address - Fax:303-427-0433
Practice Address - Street 1:2121 EAST HARMONY ROAD
Practice Address - Street 2:SUITE 160
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-0403
Practice Address - Country:US
Practice Address - Phone:970-482-3328
Practice Address - Fax:970-482-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95670033Medicaid
COC430808Medicare ID - Type Unspecified