Provider Demographics
NPI:1558531988
Name:IGNACIO FAMILY MEDICINE, INC.
Entity Type:Organization
Organization Name:IGNACIO FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIXIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:970-563-9388
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137-0707
Mailing Address - Country:US
Mailing Address - Phone:970-563-9388
Mailing Address - Fax:
Practice Address - Street 1:115 CEDAR STREET
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137
Practice Address - Country:US
Practice Address - Phone:970-563-9388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO70939363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60309067Medicaid
CO15555071Medicaid
CO60309067Medicaid
S49048Medicare UPIN