1407980675 NPI number — PHYSICAL, REHABILITATIVE AND OCCUPATIONAL MEDICINE CENTER LLC

Table of content: (NPI 1407980675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407980675 NPI number — PHYSICAL, REHABILITATIVE AND OCCUPATIONAL MEDICINE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL, REHABILITATIVE AND OCCUPATIONAL MEDICINE CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PRO MEDICINE LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407980675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
511 W 29TH ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81008-1128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-545-7802
Provider Business Mailing Address Fax Number:
719-545-7804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 W 29TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81008-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-545-7802
Provider Business Practice Location Address Fax Number:
719-545-7804
Provider Enumeration Date:
03/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CAUGHFIELD
Authorized Official First Name:
DWIGHT
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
719-545-7802

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  30495 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01304955 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".