Healthcare Provider Details

I. General information

NPI: 1619562824
Provider Name (Legal Business Name): SOUTHERN COLORADO CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 OUTLOOK BLVD STE 290
PUEBLO CO
81008-1667
US

IV. Provider business mailing address

PO BOX 9000
PUEBLO CO
81008-9000
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-2235
  • Fax: 833-916-2049
Mailing address:
  • Phone: 719-553-2235
  • Fax: 833-916-2049

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