Provider Demographics
NPI:1932501202
Name:WHOLE FAMILY HEALTH CARE OF LONGMONT
Entity Type:Organization
Organization Name:WHOLE FAMILY HEALTH CARE OF LONGMONT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN KONYNENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-776-0467
Mailing Address - Street 1:1067 S HOVER ST STE E
Mailing Address - Street 2:PMB 189
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-7903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 S AIRPORT RD
Practice Address - Street 2:BUILDING A, SUITE G
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6424
Practice Address - Country:US
Practice Address - Phone:303-776-0467
Practice Address - Fax:303-776-0467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42439261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service