Healthcare Provider Details

I. General information

NPI: 1962326660
Provider Name (Legal Business Name): PONCHA MOOR HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 FAIRVIEW AVE
CANON CITY CO
81212-2863
US

IV. Provider business mailing address

515 FAIRVIEW AVE
CANON CITY CO
81212-2863
US

V. Phone/Fax

Practice location:
  • Phone: 719-275-0665
  • Fax: 719-275-6225
Mailing address:
  • Phone: 719-275-0665
  • Fax: 719-275-6225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SOON BURNAM
Title or Position: SECRETARY
Credential:
Phone: 949-540-1249