Organization Name: | ROARING FORK DERMATOLOGY INC PC |
NPI Number: | 1578746871 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | JULIAN RAMSEY MELLETTE (OWNER) |
Mailing Address: | 23262 Two Rivers Rd Basalt |
State: | CO US |
Postal Code: | 816219227 |
Phone Number: | 9709274731 |
Fax Number: | 9709274420 |
NPI Enumeration Date: | 12/10/2007 |
NPI Last Update Date: | 06/19/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QH0100X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | CO |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Health Service |
Taxonomy Definition: |