Provider Demographics
NPI:1407980675
Name:PHYSICAL, REHABILITATIVE AND OCCUPATIONAL MEDICINE CENTER LLC
Entity Type:Organization
Organization Name:PHYSICAL, REHABILITATIVE AND OCCUPATIONAL MEDICINE CENTER LLC
Other - Org Name:PRO MEDICINE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:CAUGHFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-545-7802
Mailing Address - Street 1:511 W 29TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1128
Mailing Address - Country:US
Mailing Address - Phone:719-545-7802
Mailing Address - Fax:719-545-7804
Practice Address - Street 1:511 W 29TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1128
Practice Address - Country:US
Practice Address - Phone:719-545-7802
Practice Address - Fax:719-545-7804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30495174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01304955Medicaid
CO01304955Medicaid
COF63569Medicare UPIN