Healthcare Provider Details

I. General information

NPI: 1831705300
Provider Name (Legal Business Name): SOUTHERN COLORADO CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S BURLINGTON DR
PUEBLO WEST CO
81007-5560
US

IV. Provider business mailing address

PO BOX 9000
PUEBLO CO
81008-9000
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-2205
  • Fax:
Mailing address:
  • Phone: 719-553-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ARELLANO
Title or Position: COO
Credential:
Phone: 719-553-1801