Healthcare Provider Details

I. General information

NPI: 1194629477
Provider Name (Legal Business Name): NIKOLAS ALEJANDRO DAVILA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 BONFORTE BLVD
PUEBLO CO
81001-4901
US

IV. Provider business mailing address

5341 WARWICK ST
PUEBLO CO
81005-5539
US

V. Phone/Fax

Practice location:
  • Phone: 719-549-2100
  • Fax:
Mailing address:
  • Phone: 719-251-9870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: