Provider Demographics
NPI:1558309005
Name:SURFACE CREEK FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:SURFACE CREEK FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-856-3146
Mailing Address - Street 1:255 SW 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAREDGE
Mailing Address - State:CO
Mailing Address - Zip Code:81413-3902
Mailing Address - Country:US
Mailing Address - Phone:970-856-3146
Mailing Address - Fax:970-856-4385
Practice Address - Street 1:233 COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-4400
Practice Address - Country:US
Practice Address - Phone:970-856-3146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QH0100X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO43282067Medicaid
CO9000145531Medicaid