Healthcare Provider Details

I. General information

NPI: 1689607947
Provider Name (Legal Business Name): SOUTHWESTERN COLORADO EAR NOSE AND THROAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCADO ST SUITE 205
DURANGO CO
81301-7300
US

IV. Provider business mailing address

1 MERCADO ST SUITE 205
DURANGO CO
81301-7300
US

V. Phone/Fax

Practice location:
  • Phone: 970-385-7272
  • Fax: 970-385-7299
Mailing address:
  • Phone: 970-385-7272
  • Fax: 970-385-7299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberDR44598
License Number StateCO

VIII. Authorized Official

Name: DR. GREGORY M. SCHACKEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 970-385-7272