Provider Demographics
NPI:1386973204
Name:NEEDLEROCK FAMILY HEALTH CLINIC
Entity type:Organization
Organization Name:NEEDLEROCK FAMILY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:970-812-6403
Mailing Address - Street 1:PO BOX 104
Mailing Address - Street 2:
Mailing Address - City:CRAWFORD
Mailing Address - State:CO
Mailing Address - Zip Code:81415-0104
Mailing Address - Country:US
Mailing Address - Phone:970-812-6403
Mailing Address - Fax:
Practice Address - Street 1:375 ELM AVE
Practice Address - Street 2:
Practice Address - City:CRAWFORD
Practice Address - State:CO
Practice Address - Zip Code:81415-5011
Practice Address - Country:US
Practice Address - Phone:970-812-6403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-24
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO178811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78255856Medicaid