Provider Demographics
NPI:1023133824
Name:PAGOSA SPRINGS FAMILY MEDICINE CENTER PC
Entity type:Organization
Organization Name:PAGOSA SPRINGS FAMILY MEDICINE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-731-4131
Mailing Address - Street 1:PO BOX 7638
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 S PAGOSA BLVD
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-8330
Practice Address - Country:US
Practice Address - Phone:970-731-4131
Practice Address - Fax:970-731-9384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO74603051Medicaid
NM06D0518606OtherNM BCBS
COPAP07008OtherBCBS
6003610001Medicare NSC
COC809020Medicare PIN