Provider Demographics
NPI:1487894762
Name:PINE RIDGE FAMILY MEDICINE INC
Entity type:Organization
Organization Name:PINE RIDGE FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:VECCHIARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-550-5180
Mailing Address - Street 1:7610 N UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3861
Mailing Address - Country:US
Mailing Address - Phone:719-550-5180
Mailing Address - Fax:
Practice Address - Street 1:7610 N UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3861
Practice Address - Country:US
Practice Address - Phone:719-550-5180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-27
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31061261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care