Healthcare Provider Details

I. General information

NPI: 1124677729
Provider Name (Legal Business Name): SOCO PRIMARY CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 FORTINO BLVD STE D
PUEBLO CO
81008-2076
US

IV. Provider business mailing address

1310 FORTINO BLVD
PUEBLO CO
81008-2075
US

V. Phone/Fax

Practice location:
  • Phone: 719-582-1898
  • Fax: 719-621-4098
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NICOLE LYNN BETTS
Title or Position: PRESIDENT, AUTHORIZED OFFICIAL
Credential: NP, AGNP-C
Phone: 719-582-1898