Provider Demographics
NPI:1083642144
Name:SOUTHERN COLORADO NEPHROLOGY ASSOC PC
Entity Type:Organization
Organization Name:SOUTHERN COLORADO NEPHROLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIEBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-561-5264
Mailing Address - Street 1:3426 LAKE AVE
Mailing Address - Street 2:120
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3877
Mailing Address - Country:US
Mailing Address - Phone:719-561-5264
Mailing Address - Fax:719-561-5272
Practice Address - Street 1:3426 LAKE AVE
Practice Address - Street 2:120
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3877
Practice Address - Country:US
Practice Address - Phone:719-561-5264
Practice Address - Fax:719-561-5272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04006250Medicaid
CA1108Medicare PIN