Provider Demographics
NPI:1285703652
Name:LIFESPAN FAMILY MEDICAL SERVICES
Entity type:Organization
Organization Name:LIFESPAN FAMILY MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PASTORE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:970-484-9533
Mailing Address - Street 1:320 W OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2716
Mailing Address - Country:US
Mailing Address - Phone:970-484-9533
Mailing Address - Fax:970-484-9544
Practice Address - Street 1:320 W OLIVE ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2716
Practice Address - Country:US
Practice Address - Phone:970-484-9533
Practice Address - Fax:970-484-9544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105668261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68270348Medicaid
COP82281Medicare UPIN
COC806573Medicare PIN