Provider Demographics
NPI:1679931182
Name:HERITAGE FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:HERITAGE FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:CANHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-224-1596
Mailing Address - Street 1:1006 ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3900
Mailing Address - Country:US
Mailing Address - Phone:970-224-1596
Mailing Address - Fax:970-530-1919
Practice Address - Street 1:1006 ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3900
Practice Address - Country:US
Practice Address - Phone:970-224-1596
Practice Address - Fax:970-530-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty