Healthcare Provider Details

I. General information

NPI: 1720627011
Provider Name (Legal Business Name): PCIM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 S TEJON ST STE 120
COLORADO SPRINGS CO
80903-2139
US

IV. Provider business mailing address

1332 N WEBER ST
COLORADO SPRINGS CO
80903-2428
US

V. Phone/Fax

Practice location:
  • Phone: 719-491-1616
  • Fax: 719-591-0835
Mailing address:
  • Phone: 719-491-1616
  • Fax: 719-591-0835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM DENAM
Title or Position: DO & OWNER
Credential: DO
Phone: 719-491-1616