Provider Demographics
NPI:1093449415
Name:WAYNE HUDSON DO INTEGRATED MEDICAL PRACTICE PLLC
Entity Type:Organization
Organization Name:WAYNE HUDSON DO INTEGRATED MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:BROOKE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:719-691-2291
Mailing Address - Street 1:310 E OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-2841
Mailing Address - Country:US
Mailing Address - Phone:716-931-9844
Mailing Address - Fax:719-931-8007
Practice Address - Street 1:310 E OLIVE ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-2841
Practice Address - Country:US
Practice Address - Phone:719-691-2291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-12
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care