1275911455 NPI number — COMFORT CARE FAMILY PRACTICE, INC.

Table of content: (NPI 1275911455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275911455 NPI number — COMFORT CARE FAMILY PRACTICE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMFORT CARE FAMILY PRACTICE, INC.
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:
1275911455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
01/25/2024
NPI Reactivation Date:
02/14/2024

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5799 STETSON HILLS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80917-4223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-471-2273
Provider Business Mailing Address Fax Number:
719-380-0228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4130 N FREEWAY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81008-2064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-471-2273
Provider Business Practice Location Address Fax Number:
719-380-0228
Provider Enumeration Date:
05/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WIESCAMP
Authorized Official First Name:
ANITA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
719-510-0957

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 38904284 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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