Provider Demographics
NPI:1851743025
Name:HANSON CLINIC PC
Entity Type:Organization
Organization Name:HANSON CLINIC PC
Other - Org Name:HANSON CLINIC MRI
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-766-9004
Mailing Address - Street 1:109 S BURLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-5560
Mailing Address - Country:US
Mailing Address - Phone:719-766-9000
Mailing Address - Fax:719-766-9010
Practice Address - Street 1:109 S BURLINGTON DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-5560
Practice Address - Country:US
Practice Address - Phone:719-766-9000
Practice Address - Fax:719-766-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17496174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty