Healthcare Provider Details

I. General information

NPI: 1780288753
Provider Name (Legal Business Name): QUALITY MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3604 GALLEY RD STE 201
COLORADO SPRINGS CO
80909-4301
US

IV. Provider business mailing address

3604 GALLEY RD STE 201
COLORADO SPRINGS CO
80909-4301
US

V. Phone/Fax

Practice location:
  • Phone: 719-638-4548
  • Fax:
Mailing address:
  • Phone: 719-638-4548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JASON YISU PARK
Title or Position: CEO/ PRESIDENT
Credential: DPT
Phone: 720-240-1805