Provider Demographics
NPI:1942260377
Name:FOUR CORNERS HEART CLINIC
Entity Type:Organization
Organization Name:FOUR CORNERS HEART CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTS RECEIVABLE
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-295-8737
Mailing Address - Street 1:1800 E 3RD AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5016
Mailing Address - Country:US
Mailing Address - Phone:970-247-1120
Mailing Address - Fax:970-247-1128
Practice Address - Street 1:1800 E 3RD AVE
Practice Address - Street 2:SUITE112
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5016
Practice Address - Country:US
Practice Address - Phone:970-247-1120
Practice Address - Fax:970-247-1128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04023420Medicaid
CO04023420Medicaid