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General NPI Number Information
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NPI Number | 1972049245
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Entity Type | Organization
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Legal Business Name | DOC
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Dates
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Enumeration Date | 01/11/2017
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Last Update Date | 01/11/2017
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Provider Practice Location Address
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Address Line | 57500 E HWY 50
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City | CANON CITY
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State | CO
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Zip | 81212-9363
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Country | US
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Telephone | 719-269-5081
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Fax |
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Provider Business Mailing Address
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Address Line | 13955 MURPHY RD
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City | PEYTON
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State | CO
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Zip | 80831-9510
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Country | US
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Telephone | 171-926-9508
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MRS. TRUDY ANN SICOTTE
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Credential | ACNP
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Telephone | 719-269-5081
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number | 0004895
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License Number State | CO
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