Provider Demographics
NPI:1225017643
Name:VAIL CLINIC, INC.
Entity type:Organization
Organization Name:VAIL CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-479-7272
Mailing Address - Street 1:PO BOX 2706
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-2706
Mailing Address - Country:US
Mailing Address - Phone:970-569-7676
Mailing Address - Fax:970-569-7677
Practice Address - Street 1:322 BEARD CREEK RD
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-6426
Practice Address - Country:US
Practice Address - Phone:970-569-7676
Practice Address - Fax:970-569-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDO.14700000023336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03003720Medicaid
2003237OtherPK