Provider Demographics
NPI:1023135597
Name:NORTH PARK MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:NORTH PARK MEDICAL CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-723-4255
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:WALDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80480-0686
Mailing Address - Country:US
Mailing Address - Phone:970-723-4255
Mailing Address - Fax:970-723-4268
Practice Address - Street 1:350 MCKINLEY STREET
Practice Address - Street 2:
Practice Address - City:WALDEN
Practice Address - State:CO
Practice Address - Zip Code:80480
Practice Address - Country:US
Practice Address - Phone:970-723-4255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
063835Medicare ID - Type Unspecified