Provider Demographics
NPI:1285043125
Name:A KIDZ CLINIC
Entity type:Organization
Organization Name:A KIDZ CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOCKTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-874-2753
Mailing Address - Street 1:360 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-2379
Mailing Address - Country:US
Mailing Address - Phone:970-874-2753
Mailing Address - Fax:970-874-2943
Practice Address - Street 1:360 E 8TH ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2379
Practice Address - Country:US
Practice Address - Phone:970-874-2753
Practice Address - Fax:970-399-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2024-06-11
Deactivation Date:2018-09-13
Deactivation Code:
Reactivation Date:2018-09-19
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO89658710Medicaid