=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720627011
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PCIM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2020
-----------------------------------------------------
Last Update Date | 10/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 S TEJON ST STE 120
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80903-2139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-491-1616
-----------------------------------------------------
Fax | 719-591-0835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1332 N WEBER ST
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80903-2428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-491-1616
-----------------------------------------------------
Fax | 719-591-0835
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DO & OWNER
-----------------------------------------------------
Name | WILLIAM DENAM
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 719-491-1616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------