Organization
POTOMAC SQUARE FAMILY MEDICINE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
STEPHANIE GLUCHACKI (SVP, COMPLIANCE)
(508) 689-9706
Entity
Organization
Contact information
Practice address
4800 BASELINE RD STE D106, BOULDER, CO 80303-2643
(303) 499-0176
Mailing address
PO BOX 173848, DENVER, CO 80217-3848
(303) 945-3299
(303) 945-3303
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
—
—
261QP2300X
Primary Care Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
18903312
—
CO
Enumeration date
07/28/2020
Last updated
04/14/2022
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