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General NPI Number Information
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NPI Number | 1457498131
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Entity Type | Organization
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Legal Business Name | PEDIATRIC ASSOCIATES OF CANON CITY, PROF. LLC
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1335 PHAY AVE SUITE A
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City | CANON CITY
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State | CO
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Zip | 81212-2334
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Country | US
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Telephone | 719-269-1727
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Fax | 719-269-1730
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Provider Business Mailing Address
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Address Line | 1335 PHAY AVE SUITE A
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City | CANON CITY
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State | CO
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Zip | 81212-2334
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Country | US
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Telephone | 719-269-1727
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Fax | 719-269-1730
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | MR. ROGER DEANE NOLAND
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Credential |
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Telephone | 719-269-1727
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 23117
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License Number State | CO
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