Provider Demographics
NPI:1982623112
Name:SAN JUAN FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:SAN JUAN FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFF MGR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HORNBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-240-6136
Mailing Address - Street 1:816 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5765
Mailing Address - Country:US
Mailing Address - Phone:970-249-3322
Mailing Address - Fax:970-240-7976
Practice Address - Street 1:630 E STAR CT
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-6702
Practice Address - Country:US
Practice Address - Phone:970-240-0378
Practice Address - Fax:970-240-3346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO620398YQUNOtherMEDICARE