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General NPI Number Information
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NPI Number | 1548409139
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Entity Type | Organization
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Legal Business Name | SOUTHERN COLORADO DERMATOLOGY CLINIC PC
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Dates
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Enumeration Date | 02/05/2009
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Last Update Date | 05/25/2021
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Provider Practice Location Address
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Address Line | 900 INDIANA AVE STE C
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City | PUEBLO
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State | CO
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Zip | 81004-3767
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Country | US
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Telephone | 719-564-5544
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Fax | 719-564-2246
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Provider Business Mailing Address
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Address Line | 900 INDIANA AVE STE C
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City | PUEBLO
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State | CO
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Zip | 81004-3767
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Country | US
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Telephone | 719-564-5544
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KRYSTAL JEAN NAKAMURA
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Credential | MD
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Telephone | 719-564-5544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 44146
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License Number State | CO
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