Provider Demographics
NPI:1568559748
Name:MIDVALLEY FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:MIDVALLEY FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BORONSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-927-4666
Mailing Address - Street 1:1450 E VALLEY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621
Mailing Address - Country:US
Mailing Address - Phone:970-927-4666
Mailing Address - Fax:970-927-6623
Practice Address - Street 1:1450 E VALLEY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621
Practice Address - Country:US
Practice Address - Phone:970-927-4666
Practice Address - Fax:970-927-6623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
124Q00000X, 207Q00000X, 251S00000X, 363LF0000X
CO30756207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04826027Medicaid
COC808031Medicare UPIN
CO04826027Medicaid
CO807995Medicare PIN