Provider Demographics
NPI:1720043888
Name:DAKOTA RIDGE FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:DAKOTA RIDGE FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCCAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-443-2544
Mailing Address - Street 1:2995 BASELINE RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2318
Mailing Address - Country:US
Mailing Address - Phone:303-443-2544
Mailing Address - Fax:303-443-6476
Practice Address - Street 1:2995 BASELINE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2318
Practice Address - Country:US
Practice Address - Phone:303-443-2544
Practice Address - Fax:303-443-6476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83482270Medicaid
CO83482270Medicaid