Provider Demographics
NPI:1396052544
Name:SOUTH POINTE OCCUPATIONAL MEDICINE AND FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:SOUTH POINTE OCCUPATIONAL MEDICINE AND FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-351-2412
Mailing Address - Street 1:150 OLD LARAMIE TRAIL
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-7085
Mailing Address - Country:US
Mailing Address - Phone:970-351-3030
Mailing Address - Fax:
Practice Address - Street 1:150 OLD LARAMIE TRAIL
Practice Address - Street 2:SUITE 210
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-7085
Practice Address - Country:US
Practice Address - Phone:970-351-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2021-04-08
Deactivation Date:2017-11-28
Deactivation Code:
Reactivation Date:2017-12-04
Provider Licenses
StateLicense IDTaxonomies
CO32068261QX0100X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01320688Medicaid
E96507Medicare UPIN
C498038Medicare PIN