MEDICARE: CHARLES JEFFERY PECK, DO, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	40851	CO

General Provider Information

NPI Number	:	1427317783
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES JEFFERY PECK, DO, PC

Provider Business Mailing Address
First Line	:	4641 BRIDLE PASS DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-9266
Country	:	US
Telephone Number	:	719-640-4007
Fax Number	:

Provider Business Practice Location Address
First Line	:	4641 BRIDLE PASS DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-9266
Country	:	US
Telephone Number	:	719-640-4007
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES JEFFERY PECK
Credential	:	DO
Telephone Number	:	719-640-4007

Provider Enumeration Date	:	05/08/2012
Last Update Date	:	05/08/2012

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