Provider Demographics
NPI:1013070051
Name:WHEAT RIDGE FAMILY CLINIC PC
Entity Type:Organization
Organization Name:WHEAT RIDGE FAMILY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ARCHULETA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-940-9118
Mailing Address - Street 1:6301 W 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-5057
Mailing Address - Country:US
Mailing Address - Phone:303-940-9118
Mailing Address - Fax:303-940-5943
Practice Address - Street 1:6301 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-5057
Practice Address - Country:US
Practice Address - Phone:303-940-9118
Practice Address - Fax:303-940-5943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27027261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04017372Medicaid
COC804682Medicare ID - Type Unspecified