Provider Demographics
NPI:1609990928
Name:PLATEAU VALLEY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:PLATEAU VALLEY HOSPITAL DISTRICT
Other - Org Name:PLATEAU VALLEY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-487-3565
Mailing Address - Street 1:58128 HIGHWAY 330
Mailing Address - Street 2:
Mailing Address - City:COLLBRAN
Mailing Address - State:CO
Mailing Address - Zip Code:81624-9502
Mailing Address - Country:US
Mailing Address - Phone:970-487-3565
Mailing Address - Fax:
Practice Address - Street 1:58128 HIGHWAY 330
Practice Address - Street 2:
Practice Address - City:COLLBRAN
Practice Address - State:CO
Practice Address - Zip Code:81624-9502
Practice Address - Country:US
Practice Address - Phone:970-487-3565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04703047Medicaid
COPLR3408OtherBLUE CROSS BLUE SHIELD
CT04703047Medicaid
CO04703047Medicaid