Provider Demographics
NPI:1619152576
Name:MOUNTAINLAND PEDICATRICS INC
Entity Type:Organization
Organization Name:MOUNTAINLAND PEDICATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICE
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUCET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-853-3500
Mailing Address - Street 1:1870 W 122ND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80234-2075
Mailing Address - Country:US
Mailing Address - Phone:303-853-3500
Mailing Address - Fax:303-426-9340
Practice Address - Street 1:8889 FOX DR
Practice Address - Street 2:SUITE A
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260-8841
Practice Address - Country:US
Practice Address - Phone:303-430-0823
Practice Address - Fax:303-426-9581
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY REACH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-09
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25750208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty