Provider Demographics
NPI:1720385016
Name:ROCKY MOUNTAIN PRIMARY CARE CLINIC
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN PRIMARY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:N
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:719-924-9398
Mailing Address - Street 1:131 S MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3415
Mailing Address - Country:US
Mailing Address - Phone:719-924-9398
Mailing Address - Fax:719-924-9593
Practice Address - Street 1:131 S MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3415
Practice Address - Country:US
Practice Address - Phone:719-924-9398
Practice Address - Fax:719-924-9593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-22
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO65214363LF0000X
CO363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45256781Medicaid