Provider Demographics
NPI:1598721706
Name:MINO FAMILY HEALTH CARE, P.C.
Entity Type:Organization
Organization Name:MINO FAMILY HEALTH CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:MINO
Authorized Official - Suffix:II
Authorized Official - Credentials:DO
Authorized Official - Phone:303-776-0330
Mailing Address - Street 1:1380 TULIP ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3157
Mailing Address - Country:US
Mailing Address - Phone:303-776-0330
Mailing Address - Fax:303-772-0736
Practice Address - Street 1:1380 TULIP ST
Practice Address - Street 2:SUITE C
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3157
Practice Address - Country:US
Practice Address - Phone:303-776-0330
Practice Address - Fax:303-772-0736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32805207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87758211Medicaid
CO87758211Medicaid
COC526498Medicare ID - Type Unspecified