Provider Demographics
NPI:1720485980
Name:WILLIAM STORMS ALLERGY CLINIC, PC
Entity Type:Organization
Organization Name:WILLIAM STORMS ALLERGY CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-955-6000
Mailing Address - Street 1:1625 MEDICAL CENTER PT
Mailing Address - Street 2:SUITE 190
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-8731
Mailing Address - Country:US
Mailing Address - Phone:719-955-6000
Mailing Address - Fax:719-955-9595
Practice Address - Street 1:1625 MEDICAL CENTER PT
Practice Address - Street 2:SUITE 190
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-8731
Practice Address - Country:US
Practice Address - Phone:719-955-6000
Practice Address - Fax:719-955-9595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1184635914174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50227378Medicaid
COC802427Medicare PIN