| Organization Name: | POUDRE VALLEY MEDICAL GROUP, LLC |
| NPI Number: | 1285931865 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RULON STACEY (PRESIDENT/CEO) |
| Mailing Address: | 1327 Eagle Dr Loveland |
| State: | CO US |
| Postal Code: | 805378059 |
| Phone Number: | 9706196450 |
| Fax Number: | 9706196459 |
| NPI Enumeration Date: | 02/17/2011 |
| NPI Last Update Date: | 02/17/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |