Provider Demographics
NPI:1538920319
Name:HARVEST COLORADO FUNCTIONAL MEDICINE, LLC
Entity type:Organization
Organization Name:HARVEST COLORADO FUNCTIONAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDGINS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:303-501-4194
Mailing Address - Street 1:9249 S BROADWAY UNIT 200
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-5692
Mailing Address - Country:US
Mailing Address - Phone:303-536-7407
Mailing Address - Fax:
Practice Address - Street 1:9935 SYLVESTOR RD
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-6212
Practice Address - Country:US
Practice Address - Phone:303-501-4194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No202D00000XAllopathic & Osteopathic PhysiciansIntegrative Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty