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General NPI Number Information
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NPI Number | 1124677729
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Entity Type | Organization
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Legal Business Name | SOCO PRIMARY CARE CLINIC
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Dates
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Enumeration Date | 09/06/2019
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Last Update Date | 04/30/2020
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Provider Practice Location Address
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Address Line | 1310 FORTINO BLVD STE D
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City | PUEBLO
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State | CO
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Zip | 81008-2076
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Country | US
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Telephone | 719-582-1898
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Fax | 719-621-4098
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Provider Business Mailing Address
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Address Line | 1310 FORTINO BLVD
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City | PUEBLO
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State | CO
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Zip | 81008-2075
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT, AUTHORIZED OFFICIAL
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Name | NICOLE LYNN BETTS
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Credential | NP, AGNP-C
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Telephone | 719-582-1898
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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