Healthcare Provider Details

I. General information

NPI: 1144871492
Provider Name (Legal Business Name): CLARENCE KEON BUMPAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2565 AIRPORT RD
COLORADO SPRINGS CO
80910-3119
US

IV. Provider business mailing address

511 COMANCHE VILLAGE DR
FOUNTAIN CO
80817-1667
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-3570
  • Fax:
Mailing address:
  • Phone: 719-666-4134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberNLC.0108216
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: