Provider Demographics
NPI:1386781169
Name:VAIL VALLEY EAR NOSE AND THROAT GROUP
Entity type:Organization
Organization Name:VAIL VALLEY EAR NOSE AND THROAT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-926-6800
Mailing Address - Street 1:PO BOX 1366
Mailing Address - Street 2:105 EDWARDS VILLAGE BLVD, UNIT C202
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-1366
Mailing Address - Country:US
Mailing Address - Phone:970-926-6800
Mailing Address - Fax:970-926-6802
Practice Address - Street 1:105 EDWARDS VILLAGE BLVD UNIT C202
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-9914
Practice Address - Country:US
Practice Address - Phone:970-926-6800
Practice Address - Fax:970-926-6802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32861174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COVA657244OtherBCBS GROUP
CO87735539Medicaid
CO87735539Medicaid