Provider Demographics
NPI:1659504454
Name:WZUPDOC, INC.
Entity Type:Organization
Organization Name:WZUPDOC, INC.
Other - Org Name:WZUPDOC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:BLANE
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-579-0900
Mailing Address - Street 1:PO BOX 3104
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-3104
Mailing Address - Country:US
Mailing Address - Phone:719-579-0900
Mailing Address - Fax:719-579-0911
Practice Address - Street 1:4711 OPUS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-8694
Practice Address - Country:US
Practice Address - Phone:719-579-0900
Practice Address - Fax:719-579-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO30910261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE35408Medicare UPIN