Healthcare Provider Details

I. General information

NPI: 1750592655
Provider Name (Legal Business Name): OPEN BIBLE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E COSTILLA ST
COLORADO SPRINGS CO
80903-3764
US

IV. Provider business mailing address

555 E COSTILLA ST
COLORADO SPRINGS CO
80903-3764
US

V. Phone/Fax

Practice location:
  • Phone: 719-596-4449
  • Fax: 719-574-6686
Mailing address:
  • Phone: 719-475-0972
  • Fax: 719-475-0322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFERSON D. MARTIN JR.
Title or Position: PASTOR
Credential:
Phone: 719-475-0972