Provider Demographics
NPI:1831547363
Name:MOUNTAIN PEAKS FAMILY PRACTICE PC
Entity type:Organization
Organization Name:MOUNTAIN PEAKS FAMILY PRACTICE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-216-6199
Mailing Address - Street 1:836 S TOWNSEND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-4360
Mailing Address - Country:US
Mailing Address - Phone:970-615-9120
Mailing Address - Fax:970-240-1139
Practice Address - Street 1:836 S TOWNSEND AVE STE A
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4360
Practice Address - Country:US
Practice Address - Phone:970-615-9120
Practice Address - Fax:970-240-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
622111300OtherDEPT OF LABOR: FECA, BLACK LUNG, ENERGY
CO50825330Medicaid
DW8070OtherRAILROAD WORKERS MEDICARE PTAN
622111300OtherDEPT OF LABOR: FECA, BLACK LUNG, ENERGY