Basic Information
| Provider Information | |||||||||
| NPI: | 1285613554 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN COLORADO CLINIC PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9000 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810089000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195532200 | ||||||||
| FaxNumber: | 7195532216 | ||||||||
| Practice Location | |||||||||
| Address1: | 3676 PARKER BLVD | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195532200 | ||||||||
| FaxNumber: | 7195532213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 07/18/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POTZLER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | STEWART | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7195532200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MEDICAL DOCTOR | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.