Provider Demographics
NPI:1053859009
Name:PROSTHETIC & ORTHOTIC GROUP - SOUTHERN COLORADO, LLC
Entity Type:Organization
Organization Name:PROSTHETIC & ORTHOTIC GROUP - SOUTHERN COLORADO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:719-542-1313
Mailing Address - Street 1:415 N GREENWOOD ST STE E
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3173
Mailing Address - Country:US
Mailing Address - Phone:719-542-1313
Mailing Address - Fax:719-542-9140
Practice Address - Street 1:415 N GREENWOOD ST STE E
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3173
Practice Address - Country:US
Practice Address - Phone:719-542-1313
Practice Address - Fax:719-542-9140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier