Provider Demographics
NPI:1568511855
Name:MOFFAT FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:MOFFAT FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-824-3252
Mailing Address - Street 1:600 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:CRAIG
Mailing Address - State:CO
Mailing Address - Zip Code:81625-2018
Mailing Address - Country:US
Mailing Address - Phone:970-824-3252
Mailing Address - Fax:970-824-8025
Practice Address - Street 1:600 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625-2018
Practice Address - Country:US
Practice Address - Phone:970-824-3252
Practice Address - Fax:970-824-8025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04624045Medicaid
COCS7054OtherANTHEM
CO1568511855Medicare PIN
COCS7054OtherANTHEM