Healthcare Provider Details

I. General information

NPI: 1205860905
Provider Name (Legal Business Name): BECKY S. SCHACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 24TH ST
PUEBLO CO
81003-1411
US

IV. Provider business mailing address

1600 W 24TH ST
PUEBLO CO
81003-1411
US

V. Phone/Fax

Practice location:
  • Phone: 719-546-4789
  • Fax:
Mailing address:
  • Phone: 719-546-4789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: