Provider Demographics
NPI:1386261493
Name:KEYSTONE PRIMARY CARE LLC
Entity type:Organization
Organization Name:KEYSTONE PRIMARY CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:MS
Authorized Official - First Name:FATIMAH
Authorized Official - Middle Name:AISHA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:AG-NP
Authorized Official - Phone:303-755-5542
Mailing Address - Street 1:11111 E MISSISSIPPI AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-3106
Mailing Address - Country:US
Mailing Address - Phone:303-755-5542
Mailing Address - Fax:720-749-2121
Practice Address - Street 1:11111 E MISSISSIPPI AVE STE 112
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3106
Practice Address - Country:US
Practice Address - Phone:303-755-5542
Practice Address - Fax:720-749-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1871081737OtherNPI
653232OtherMEDICARE
CO0993831OtherNP LIC
CO0993831OtherNP LIC