Provider Demographics
NPI:1033164991
Name:SOUTHWEST DIAGNOSTIC CENTERS OF COLORADO SPRINGS
Entity Type:Organization
Organization Name:SOUTHWEST DIAGNOSTIC CENTERS OF COLORADO SPRINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-380-7210
Mailing Address - Street 1:2020 NORTH ACADEMY BLVD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1567
Mailing Address - Country:US
Mailing Address - Phone:719-380-7210
Mailing Address - Fax:719-380-7510
Practice Address - Street 1:2020 N ACADEMY BLVD
Practice Address - Street 2:SUITE 155
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1567
Practice Address - Country:US
Practice Address - Phone:719-380-7210
Practice Address - Fax:719-380-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08982511Medicaid
CO442688Medicare ID - Type Unspecified
COC442688Medicare PIN
CO00824Medicare UPIN