Provider Demographics
NPI:1215250873
Name:STOVER WADE CORPORATION
Entity type:Organization
Organization Name:STOVER WADE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-856-4111
Mailing Address - Street 1:836 S TOWNSEND AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-4360
Mailing Address - Country:US
Mailing Address - Phone:970-249-2118
Mailing Address - Fax:970-249-2187
Practice Address - Street 1:836 S TOWNSEND AVE STE C
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4360
Practice Address - Country:US
Practice Address - Phone:970-249-2118
Practice Address - Fax:970-249-2187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32008207P00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98901257Medicaid