Provider Demographics
NPI:1720412760
Name:NIESCHBURG, KARL (BA)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:
Last Name:NIESCHBURG
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 BARNES AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050
Mailing Address - Country:US
Mailing Address - Phone:719-384-5446
Mailing Address - Fax:719-384-5672
Practice Address - Street 1:100 KENDALL DR
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052
Practice Address - Country:US
Practice Address - Phone:719-336-7501
Practice Address - Fax:719-336-7453
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator