Healthcare Provider Details

I. General information

NPI: 1104897693
Provider Name (Legal Business Name): EVANS ARMY COMMUNITY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR
FT CARSON CO
80913-4603
US

IV. Provider business mailing address

9351 BAR B RD
FOUNTAIN CO
80817-3390
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-4373
  • Fax:
Mailing address:
  • Phone: 719-382-9141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number18334
License Number StateCO

VIII. Authorized Official

Name: MRS. AVIS ELLEN VENCILL
Title or Position: LPN
Credential: LPN
Phone: 719-524-4373