Provider Demographics
NPI:1861486219
Name:CLEAR CREEK FAMILY PRACTICE
Entity Type:Organization
Organization Name:CLEAR CREEK FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:LYNA
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-232-5354
Mailing Address - Street 1:7615 W 38TH AVE
Mailing Address - Street 2:STE B117
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6172
Mailing Address - Country:US
Mailing Address - Phone:303-232-5354
Mailing Address - Fax:303-239-8878
Practice Address - Street 1:7615 W 38TH AVE
Practice Address - Street 2:STE B117
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6172
Practice Address - Country:US
Practice Address - Phone:303-232-5354
Practice Address - Fax:303-239-8878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G18594Medicare UPIN
CO508858Medicare ID - Type Unspecified