Provider Demographics
NPI:1700174133
Name:SOPRIS WOMEN'S CLINIC
Entity Type:Organization
Organization Name:SOPRIS WOMEN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LLC
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TREADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:970-355-9686
Mailing Address - Street 1:410 20TH ST
Mailing Address - Street 2:STE 102
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4271
Mailing Address - Country:US
Mailing Address - Phone:970-355-9686
Mailing Address - Fax:
Practice Address - Street 1:410 20TH ST
Practice Address - Street 2:STE 102
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4271
Practice Address - Country:US
Practice Address - Phone:970-355-9686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO123427367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO72057840Medicaid