Provider Demographics
NPI:1578746871
Name:ROARING FORK DERMATOLOGY INC PC
Entity Type:Organization
Organization Name:ROARING FORK DERMATOLOGY INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:RAMSEY
Authorized Official - Last Name:MELLETTE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:970-927-4731
Mailing Address - Street 1:PO BOX 1489
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-1489
Mailing Address - Country:US
Mailing Address - Phone:970-927-4731
Mailing Address - Fax:970-927-4420
Practice Address - Street 1:23262 TWO RIVERS RD
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-9227
Practice Address - Country:US
Practice Address - Phone:970-927-4731
Practice Address - Fax:970-927-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service