Organization
HERON LAKE LLC
Active
Parent organization
HERON LAKE LLC
Other names
Foxtrail Family Medicine
Organization subpart
Yes
Provider details
NPI number
Legal business name
HERON LAKE LLC
Authorized official
STEPHANIE DOUGHTY (CFO)
(970) 237-7003
Entity
Organization
Contact information
Practice address
1625 FOXTRAIL DR, STE 190, LOVELAND, CO 80538-9088
(970) 619-6900
(970) 619-6990
Mailing address
2695 ROCKY MOUNTAIN AVE, STE 150, LOVELAND, CO 80538-8702
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
92181031
—
CO
Enumeration date
08/05/2008
Last updated
01/14/2014
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