Provider Demographics
NPI:1205162062
Name:MOUNTAIN PEAKS DIAGNOSTICS
Entity type:Organization
Organization Name:MOUNTAIN PEAKS DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RUNYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-429-5076
Mailing Address - Street 1:818 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:502 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3336
Practice Address - Country:US
Practice Address - Phone:719-429-5076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory