=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790677680
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN COLORADO CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2025
-----------------------------------------------------
Last Update Date | 07/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 314 W 16TH ST
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81003-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-553-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9000
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81008-9000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-553-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | JACK MYERS
-----------------------------------------------------
Credential | PRACTICE MANAGER
-----------------------------------------------------
Telephone | 719-553-2201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------