=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427317783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES JEFFERY PECK, DO, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2012
-----------------------------------------------------
Last Update Date | 05/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4641 BRIDLE PASS DR
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80923-9266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-640-4007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4641 BRIDLE PASS DR
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80923-9266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-640-4007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHARLES JEFFERY PECK
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 719-640-4007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 40851
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------