Provider Demographics
NPI:1659435535
Name:SOUTHERN COLORADO CLINIC
Entity Type:Organization
Organization Name:SOUTHERN COLORADO CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:POTZLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-553-1802
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:719-553-2216
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2212
Practice Address - Country:US
Practice Address - Phone:719-553-2200
Practice Address - Fax:719-553-2216
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN COLORADO CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-21
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
COV8008Medicare ID - Type Unspecified