Healthcare Provider Details

I. General information

NPI: 1396389680
Provider Name (Legal Business Name): RETINA CONSULTANTS OF SOUTHERN COLORADO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 PARKER BLVD
PUEBLO CO
81008-2278
US

IV. Provider business mailing address

2770 N UNION BLVD STE 140
COLORADO SPRINGS CO
80909-1183
US

V. Phone/Fax

Practice location:
  • Phone: 719-473-9595
  • Fax: 719-227-0669
Mailing address:
  • Phone: 719-473-9595
  • Fax: 719-227-0669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE DARLENE BEAL
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 719-473-9595