MEDICARE: WZUPDOC, INC.

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	261QP2300X	Primary Care Clinic/Center	CO30910	CO

General Provider Information

NPI Number	:	1659504454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WZUPDOC, INC.

Provider Business Mailing Address
First Line	:	PO BOX 3104
Second Line	:
City	:	MONUMENT
State	:	CO
Zip	:	80132-3104
Country	:	US
Telephone Number	:	719-579-0900
Fax Number	:	719-579-0911

Provider Business Practice Location Address
First Line	:	4711 OPUS RD
Second Line	:	SUITE 201
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8694
Country	:	US
Telephone Number	:	719-579-0900
Fax Number	:	719-579-0911

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GARY BLANE CHILDERS
Credential	:	M.D.
Telephone Number	:	719-579-0900

Provider Enumeration Date	:	08/26/2009
Last Update Date	:	08/26/2009

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