| NPI | 1417455403 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BEVERLY J CLARK Credentialing COO Rdinator 970-254-2642 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine |
| Enumeration Date | 2018-01-25 |
| Last Update Date | 2022-01-04 |