Provider Demographics
NPI:1205881174
Name:MOUNTAIN VISTA ORTHOPAEDICS
Entity type:Organization
Organization Name:MOUNTAIN VISTA ORTHOPAEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-348-0020
Mailing Address - Street 1:5890 W 13TH ST
Mailing Address - Street 2:101
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4816
Mailing Address - Country:US
Mailing Address - Phone:970-348-0020
Mailing Address - Fax:970-348-0055
Practice Address - Street 1:5890 W 13TH ST
Practice Address - Street 2:101
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4816
Practice Address - Country:US
Practice Address - Phone:970-348-0020
Practice Address - Fax:970-348-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04007357Medicaid
COC17404Medicare PIN