1750954905 NPI number — JENNIFER GWEN CHAMBERS SIMMONS RD

Table of content: JENNIFER GWEN CHAMBERS SIMMONS RD (NPI 1750954905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750954905 NPI number — JENNIFER GWEN CHAMBERS SIMMONS RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAMBERS SIMMONS
Provider First Name:
JENNIFER
Provider Middle Name:
GWEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

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:
1750954905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81008-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-553-1808
Provider Business Mailing Address Fax Number:
719-553-2216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3676 PARKER BLVD
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:
81008-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-553-1808
Provider Business Practice Location Address Fax Number:
719-553-2216
Provider Enumeration Date:
07/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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