Healthcare Provider Details

I. General information

NPI: 1679059687
Provider Name (Legal Business Name): BUPDOC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 N ACADEMY BLVD STE 3
COLORADO SPRINGS CO
80917-5115
US

IV. Provider business mailing address

3220 N ACADEMY BLVD STE 3
COLORADO SPRINGS CO
80917-5115
US

V. Phone/Fax

Practice location:
  • Phone: 719-445-0383
  • Fax: 719-375-0953
Mailing address:
  • Phone: 719-445-0383
  • Fax: 719-375-0953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number32462
License Number StateCO

VIII. Authorized Official

Name: CONNIE RENEE NALLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 719-445-0383