=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811406630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN COLORADO HEARING ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2017
-----------------------------------------------------
Last Update Date | 09/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 904 EAST HAILEY LANE
-----------------------------------------------------
City | PUEBLO WEST
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-252-9909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5936 REBA CT
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-8708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-252-9909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUDIOLOGIST
-----------------------------------------------------
Name | DR. ANDRAE CHRISTINA LUCAS
-----------------------------------------------------
Credential | AU.D.
-----------------------------------------------------
Telephone | 719-252-9909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 353
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------