Provider Demographics
NPI:1194728444
Name:MONTROSE WELLNESS CENTER PC
Entity type:Organization
Organization Name:MONTROSE WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZZETTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-252-9644
Mailing Address - Street 1:PO BOX 1664
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81402-1664
Mailing Address - Country:US
Mailing Address - Phone:970-252-9644
Mailing Address - Fax:970-252-9646
Practice Address - Street 1:224 S NEVADA AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4234
Practice Address - Country:US
Practice Address - Phone:970-252-9644
Practice Address - Fax:970-252-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04023917Medicaid
COC337008Medicare ID - Type Unspecified