Provider Demographics
NPI:1316120991
Name:NEPHROLOGY CLINIC PC
Entity type:Organization
Organization Name:NEPHROLOGY CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TOBEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-493-7733
Mailing Address - Street 1:1600 SPECHT POINT RD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:FT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4311
Mailing Address - Country:US
Mailing Address - Phone:970-493-7733
Mailing Address - Fax:970-493-8745
Practice Address - Street 1:3116 WILLET DR
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072
Practice Address - Country:US
Practice Address - Phone:970-493-7733
Practice Address - Fax:970-493-8745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9596Medicare PIN