Healthcare Provider Details

I. General information

NPI: 1528136777
Provider Name (Legal Business Name): JOHN STANLEY MISHASEK CPED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N UNION BLVD
COLORADO SPRINGS CO
80909-1107
US

IV. Provider business mailing address

2415 N UNION BLVD
COLORADO SPRINGS CO
80909-1107
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-4275
  • Fax: 719-471-0760
Mailing address:
  • Phone: 719-632-4275
  • Fax: 719-471-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: