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General NPI Number Information
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NPI Number | 1083833834
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Entity Type | Organization
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Legal Business Name | ACADEMIC NEUROLOGY & HEADACHE CLINIC PC
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 12/14/2009
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Provider Practice Location Address
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Address Line | 2301 E PIKES PEAK AVE SUITE 202
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City | COLORADO SPRINGS
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State | CO
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Zip | 80909-8006
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Country | US
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Telephone | 719-630-1510
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Fax | 719-632-7343
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Provider Business Mailing Address
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Address Line | 2301 E PIKES PEAK AVE
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City | COLORADO SPRINGS
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State | CO
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Zip | 80909-8006
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Country | US
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Telephone | 719-630-1510
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Fax | 719-632-7343
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRUCE H PETERS
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Credential | M.D.
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Telephone | 719-630-1510
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 24546
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License Number State | CO
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