Basic Information
| Provider Information | |||||||||
| NPI: | 1033164991 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST DIAGNOSTIC CENTERS OF COLORADO SPRINGS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 NORTH ACADEMY BLVD | ||||||||
| Address2: | SUITE 155 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809091567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193807210 | ||||||||
| FaxNumber: | 7193807510 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 N ACADEMY BLVD | ||||||||
| Address2: | SUITE 155 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809091567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193807210 | ||||||||
| FaxNumber: | 7193807510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7193807210 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 08982511 | 05 | CO | MEDICAID |