Healthcare Provider Details

I. General information

NPI: 1538791330
Provider Name (Legal Business Name): SOARING EAGLES CENTER FOR AUTISM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W PALMER LAKE DR
PUEBLO WEST CO
81007-2876
US

IV. Provider business mailing address

PO BOX 7878
PUEBLO WEST CO
81007-0878
US

V. Phone/Fax

Practice location:
  • Phone: 719-547-8803
  • Fax: 719-547-8806
Mailing address:
  • Phone: 719-547-8803
  • Fax: 719-547-8806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KAREN W. COLVIN
Title or Position: EXECUTIVE DIRECTOR
Credential: MD
Phone: 719-547-8803