Healthcare Provider Details

I. General information

NPI: 1154971661
Provider Name (Legal Business Name): OLD COLORADO CITY WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W COLORADO AVE # 303
COLORADO SPRINGS CO
80904-3882
US

IV. Provider business mailing address

2020 W COLORADO AVE # 303
COLORADO SPRINGS CO
80904-3882
US

V. Phone/Fax

Practice location:
  • Phone: 719-473-2368
  • Fax: 719-473-4581
Mailing address:
  • Phone: 719-473-2368
  • Fax: 719-473-4581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JILL ELENE SMOTHERS
Title or Position: OWNER/MANAGING MEMBER
Credential: FNP, BC
Phone: 719-473-2368