Provider Demographics
NPI:1598371056
Name:SOUTHERN COLORADO CLINIC PC
Entity Type:Organization
Organization Name:SOUTHERN COLORADO CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ARELLANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-553-1801
Mailing Address - Street 1:PO BOX 9000
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-9000
Mailing Address - Country:US
Mailing Address - Phone:719-553-2200
Mailing Address - Fax:
Practice Address - Street 1:3937 IVYWOOD LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2551
Practice Address - Country:US
Practice Address - Phone:719-553-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN COLORADO CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-21
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center