Healthcare Provider Details

I. General information

NPI: 1083642144
Provider Name (Legal Business Name): SOUTHERN COLORADO NEPHROLOGY ASSOC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3426 LAKE AVE 120
PUEBLO CO
81004-3877
US

IV. Provider business mailing address

3426 LAKE AVE 120
PUEBLO CO
81004-3877
US

V. Phone/Fax

Practice location:
  • Phone: 719-561-5264
  • Fax: 719-561-5272
Mailing address:
  • Phone: 719-561-5264
  • Fax: 719-561-5272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: JULIETTE GIEBEL
Title or Position: OFFICE MANAGER
Credential:
Phone: 719-561-5264