Healthcare Provider Details

I. General information

NPI: 1790677680
Provider Name (Legal Business Name): SOUTHERN COLORADO CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W 16TH ST
PUEBLO CO
81003-2728
US

IV. Provider business mailing address

PO BOX 9000
PUEBLO CO
81008-9000
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-2200
  • 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: JACK MYERS
Title or Position: PRACTICE MANAGER
Credential: PRACTICE MANAGER
Phone: 719-553-2201