Provider Demographics
NPI:1831694231
Name:PEDIATRIC ASSOCIATES PROF LLC
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES PROF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-249-2421
Mailing Address - Street 1:947 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5716
Mailing Address - Country:US
Mailing Address - Phone:970-249-2421
Mailing Address - Fax:970-249-1203
Practice Address - Street 1:242 COTTONWOOD ST STE 101
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-4404
Practice Address - Country:US
Practice Address - Phone:970-874-7552
Practice Address - Fax:970-874-7554
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ASSOCIATES PROF LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-27
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty