Provider Demographics
NPI:1285282137
Name:CASTLE VALLEY CHILDREN'S CLINIC
Entity type:Organization
Organization Name:CASTLE VALLEY CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JO
Authorized Official - Middle Name:ELLYN
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-984-3333
Mailing Address - Street 1:820 CASTLE VALLEY BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:CO
Mailing Address - Zip Code:81647-9453
Mailing Address - Country:US
Mailing Address - Phone:970-984-3333
Mailing Address - Fax:970-984-0293
Practice Address - Street 1:2615 DOLORES WAY UNIT 103
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-2238
Practice Address - Country:US
Practice Address - Phone:970-984-3333
Practice Address - Fax:970-984-0293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-03
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08189731Medicaid