Provider Demographics
NPI:1578184230
Name:CIRQUE MEADOW PSYCHIATRY
Entity Type:Organization
Organization Name:CIRQUE MEADOW PSYCHIATRY
Other - Org Name:CIRQUE MEADOW PSYCHIATRY VIRGINIA CARYL MACK SOLE MBR
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:360-621-1409
Mailing Address - Street 1:415 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2571
Mailing Address - Country:US
Mailing Address - Phone:360-621-1409
Mailing Address - Fax:848-213-0217
Practice Address - Street 1:CIRQUE MEADOW PSYCHIATRY
Practice Address - Street 2:211 WEST MYRTE STREET, SUITE 207
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2971
Practice Address - Country:US
Practice Address - Phone:360-621-1409
Practice Address - Fax:848-213-0217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-04
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COAPN0990068-NPOtherMEDICAL LICENSE