Provider Demographics
NPI:1730279712
Name:VVMC DIVERSIFIED SERVICES
Entity Type:Organization
Organization Name:VVMC DIVERSIFIED SERVICES
Other - Org Name:NORTHSTAR UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:CREVLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-479-7238
Mailing Address - Street 1:PO BOX 848997
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8997
Mailing Address - Country:US
Mailing Address - Phone:970-777-2834
Mailing Address - Fax:970-777-2929
Practice Address - Street 1:320 BEARD CREEK ROAD
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-569-7725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAIL CLINIC INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-13
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0786174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01926721Medicaid
CO01926721Medicaid