Provider Demographics
NPI:1417538281
Name:TEN MILE HEALTH & WELLNESS LLC
Entity type:Organization
Organization Name:TEN MILE HEALTH & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:LARKIN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-455-9004
Mailing Address - Street 1:PO BOX 2098
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:CO
Mailing Address - Zip Code:80435-2098
Mailing Address - Country:US
Mailing Address - Phone:970-455-9004
Mailing Address - Fax:949-577-4247
Practice Address - Street 1:114 VILLAGE PLACE
Practice Address - Street 2:ST 207
Practice Address - City:DILLON
Practice Address - State:CO
Practice Address - Zip Code:80435
Practice Address - Country:US
Practice Address - Phone:970-455-9004
Practice Address - Fax:949-577-4247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000169353Medicaid