1114751153 NPI number — COLORADO SPRINGS DIRECT PRIMARY CARE

Table of content: (NPI 1114751153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114751153 NPI number — COLORADO SPRINGS DIRECT PRIMARY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORADO SPRINGS DIRECT PRIMARY CARE
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:
Provider Other Organization Name Type Code:
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:
1114751153
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6510-A SOUTH ACADEMY BLVD
Provider Second Line Business Mailing Address:
PMB 206
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-362-5152
Provider Business Mailing Address Fax Number:
719-888-1592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4711 OPUS DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80906-8718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-362-5152
Provider Business Practice Location Address Fax Number:
719-888-1592
Provider Enumeration Date:
08/30/2024

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIS
Authorized Official First Name:
CORNELIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
719-362-5152

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com