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General NPI Number Information
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NPI Number | 1578910790
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Entity Type | Organization
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Legal Business Name | PENROSE FAMILY HEALTH CLINIC
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Dates
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Enumeration Date | 05/17/2016
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Last Update Date | 05/17/2016
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Provider Practice Location Address
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Address Line | 91 ILLINOIS ST
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City | PENROSE
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State | CO
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Zip | 81240-9683
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Country | US
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Telephone | 719-372-6555
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Fax |
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Provider Business Mailing Address
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Address Line | 91 ILLINOIS ST
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City | PENROSE
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State | CO
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Zip | 81240-9683
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Country | US
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Telephone | 719-372-6555
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Fax |
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | MADELEINE JACOBS
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Credential | M.D.
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Telephone | 719-372-6555
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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 | 27100
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License Number State | CO
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