Healthcare Provider Details

I. General information

NPI: 1861377541
Provider Name (Legal Business Name): COBC BRANDS DIRECT PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 SOLITAIRE ST
COLORADO SPRINGS CO
80905-4255
US

IV. Provider business mailing address

1497 SOLITAIRE ST
COLORADO SPRINGS CO
80905-4255
US

V. Phone/Fax

Practice location:
  • Phone: 440-371-3063
  • Fax:
Mailing address:
  • Phone: 440-371-3063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LOGAN CRIST
Title or Position: PROVIDER
Credential: PA-C
Phone: 440-371-3063