Provider Demographics
NPI:1659704104
Name:PVHS-ICM EMPLOYEE HEALTH AND WELLNESS, LLC
Entity Type:Organization
Organization Name:PVHS-ICM EMPLOYEE HEALTH AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-237-6339
Mailing Address - Street 1:2211 S COLLEGE AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1489
Mailing Address - Country:US
Mailing Address - Phone:970-237-6339
Mailing Address - Fax:970-482-2091
Practice Address - Street 1:2211 S COLLEGE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1489
Practice Address - Country:US
Practice Address - Phone:970-237-6339
Practice Address - Fax:970-482-2091
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASSOCIATES FAMILY MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center