Provider Demographics
NPI:1760956924
Name:MOUNTAIN TRAIL MEDICAL
Entity Type:Organization
Organization Name:MOUNTAIN TRAIL MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:307-320-7075
Mailing Address - Street 1:1001A E HARMONY RD # 338
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3354
Mailing Address - Country:US
Mailing Address - Phone:307-314-3330
Mailing Address - Fax:
Practice Address - Street 1:542 16TH ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5241
Practice Address - Country:US
Practice Address - Phone:307-324-2759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-21
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty