Healthcare Provider Details

I. General information

NPI: 1346625621
Provider Name (Legal Business Name): TIA CLAYBROOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 ZAIGER PL
COLORADO SPRINGS CO
80915-2248
US

IV. Provider business mailing address

1506 ZAIGER PL
COLORADO SPRINGS CO
80915-2248
US

V. Phone/Fax

Practice location:
  • Phone: 719-287-2902
  • Fax: 719-265-1752
Mailing address:
  • Phone: 719-287-2902
  • Fax: 719-265-1752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberMT0008471
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: