Healthcare Provider Details

I. General information

NPI: 1124687926
Provider Name (Legal Business Name): COMPLETE CARE OFFICE ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9320 GRAND CORDERA PKWY
COLORADO SPRINGS CO
80924-7003
US

IV. Provider business mailing address

4970 WOODLEY AVE
SEDALIA CO
80135-8976
US

V. Phone/Fax

Practice location:
  • Phone: 719-258-1250
  • Fax:
Mailing address:
  • Phone: 720-763-0499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CARRIE DIEHL
Title or Position: PHYSICIAN
Credential:
Phone: 720-763-0499