Basic Information
| Provider Information | |||||||||
| NPI: | 1093322547 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN COLORADO HEALTH & REHAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5718 | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599035718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067560134 | ||||||||
| FaxNumber: | 4063001612 | ||||||||
| Practice Location | |||||||||
| Address1: | 1630 FORTINO BLVD | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810081856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192813184 | ||||||||
| FaxNumber: | 7192994088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2020 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | STIMAC | ||||||||
| AuthorizedOfficialFirstName: | BLAINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4067561128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN COLORADO HEALTH & REHAB LLC | ||||||||
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| AuthorizedOfficialCredential: | MSPT | ||||||||
| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.