Provider Demographics
NPI:1699214130
Name:WESTERN SLOPE FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:WESTERN SLOPE FAMILY MEDICINE, PLLC
Other - Org Name:PAVILION FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CORENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-315-1595
Mailing Address - Street 1:1804 E PAVILION PL
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5795
Mailing Address - Country:US
Mailing Address - Phone:207-315-1595
Mailing Address - Fax:
Practice Address - Street 1:1804 E PAVILION PL
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5795
Practice Address - Country:US
Practice Address - Phone:970-249-6770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR 0057738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty