Provider Demographics
NPI:1578766689
Name:CASTLE VALLEY CHILDREN'S CLINIC
Entity Type:Organization
Organization Name:CASTLE VALLEY CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:970-984-3333
Mailing Address - Street 1:820 CASTLE VALLEY BLVD
Mailing Address - Street 2:SUITE #204
Mailing Address - City:NEW CASTLE
Mailing Address - State:CO
Mailing Address - Zip Code:81647-9480
Mailing Address - Country:US
Mailing Address - Phone:970-984-3333
Mailing Address - Fax:970-984-0293
Practice Address - Street 1:820 CASTLE VALLEY BLVD
Practice Address - Street 2:SUITE #204
Practice Address - City:NEW CASTLE
Practice Address - State:CO
Practice Address - Zip Code:81647-9480
Practice Address - Country:US
Practice Address - Phone:970-984-3333
Practice Address - Fax:970-984-0293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
CO83645363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08189731Medicaid
CO57507732Medicaid