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General NPI Number Information
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NPI Number | 1730049115
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Entity Type | Organization
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Legal Business Name | PEDIATRIC NEUROLOGY AND EPILEPSY SPECIALISTS, PLLC
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Dates
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Enumeration Date | 11/17/2025
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Last Update Date | 11/17/2025
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Provider Practice Location Address
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Address Line | 2021 N BOISE AVE
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City | LOVELAND
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State | CO
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Zip | 80538-5037
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Country | US
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Telephone | 303-226-7230
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Fax |
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Provider Business Mailing Address
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Address Line | 9235 N UNION BLVD STE 150334
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City | COLORADO SPRINGS
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State | CO
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Zip | 80920-7831
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Country | US
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Telephone | 303-226-7230
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | ALICIA LICANO
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Credential |
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Telephone | 719-638-1122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0402X
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Taxonomy Name | Neurology with Special Qualifications in Child Neurology Physician
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License Number |
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License Number State |
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