Provider Demographics
NPI:1780919712
Name:PINE RIVER HEALTH CARE, INC.
Entity type:Organization
Organization Name:PINE RIVER HEALTH CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKER
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:970-884-5173
Mailing Address - Street 1:480 WOLVERINE DR
Mailing Address - Street 2:#2B
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-9653
Mailing Address - Country:US
Mailing Address - Phone:970-884-5173
Mailing Address - Fax:970-884-0123
Practice Address - Street 1:480 WOLVERINE DR
Practice Address - Street 2:#2B
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122-9653
Practice Address - Country:US
Practice Address - Phone:970-884-5173
Practice Address - Fax:970-884-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO174732363LA2200X, 363LP2300X, 363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1982704441OtherINDIVIDUAL NPI