Provider Demographics
NPI:1740992676
Name:PRAIRIE CLINIC LLC
Entity type:Organization
Organization Name:PRAIRIE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LLC MEMBER/MEDICAL PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TENNILLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RAU
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:719-691-4642
Mailing Address - Street 1:172 WEST 1ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81073-9716
Mailing Address - Country:US
Mailing Address - Phone:719-691-4488
Mailing Address - Fax:
Practice Address - Street 1:172 WEST 1ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:CO
Practice Address - Zip Code:81073-8107
Practice Address - Country:US
Practice Address - Phone:719-691-4488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-22
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1114384138OtherNPI 1