Healthcare Provider Details

I. General information

NPI: 1063727444
Provider Name (Legal Business Name): DR DEBRA IRIZARRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

46 CAMINO BACA GRANDE 102
CRESTONE CO
81131
US

IV. Provider business mailing address

PO BOX 749
CRESTONE CO
81131-0749
US

V. Phone/Fax

Practice location:
  • Phone: 719-256-6600
  • Fax: 719-256-6600
Mailing address:
  • Phone: 719-256-6600
  • Fax: 719-256-6600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number46205
License Number StateCO

VIII. Authorized Official

Name: DR. DEBRA IRIZARRY
Title or Position: PROPRIETOR
Credential:
Phone: 719-256-6600