Provider Demographics
NPI:1588704027
Name:HIGH PLAINS MEDICAL LLC
Entity type:Organization
Organization Name:HIGH PLAINS MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CJ
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-353-3316
Mailing Address - Street 1:PO BOX 1809
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80632-1809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:914 11TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-3822
Practice Address - Country:US
Practice Address - Phone:970-353-3316
Practice Address - Fax:970-353-3947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42742850001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121877OtherPK
CO67957358Medicaid