Healthcare Provider Details

I. General information

NPI: 1417288804
Provider Name (Legal Business Name): ROD EUGENE RUSHING CAC II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 S 21ST ST
COLORADO SPRINGS CO
80904-3708
US

IV. Provider business mailing address

1102 S 21ST ST LOWR LEVEL
COLORADO SPRINGS CO
80904-3708
US

V. Phone/Fax

Practice location:
  • Phone: 303-436-4727
  • Fax: 303-436-4779
Mailing address:
  • Phone: 800-604-8978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACC.0006985
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: