Provider Demographics
NPI:1013490259
Name:ADVANCED PRACTICE HEADACHE AND PRIMARY CARE CLINIC
Entity type:Organization
Organization Name:ADVANCED PRACTICE HEADACHE AND PRIMARY CARE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZSUZSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASSCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:719-778-1414
Mailing Address - Street 1:1128 EAGLERIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2103
Mailing Address - Country:US
Mailing Address - Phone:719-778-1414
Mailing Address - Fax:719-674-1000
Practice Address - Street 1:1128 EAGLERIDGE BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008
Practice Address - Country:US
Practice Address - Phone:719-778-1414
Practice Address - Fax:719-674-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-13
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty