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General NPI Number Information
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NPI Number | 1316561558
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Entity Type | Organization
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Legal Business Name | SUMMIT PRIMARY CARE
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Dates
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Enumeration Date | 06/03/2020
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Last Update Date | 10/01/2020
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Provider Practice Location Address
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Address Line | 1120 MINNEQUA AVE
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City | PUEBLO
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State | CO
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Zip | 81004-3734
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Country | US
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Telephone | 719-281-3285
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5300
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City | COLORADO SPRINGS
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State | CO
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Zip | 80931-5300
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Country | US
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Telephone | 303-253-0896
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | NICOLE DENNIS
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Credential |
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Telephone | 193-008-4337
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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