Basic Information
| Provider Information | |||||||||
| NPI: | 1639689904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVANS ARMY COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARSON CBPCC PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COCHRANE CIR | ||||||||
| Address2: | |||||||||
| City: | FT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134604 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 565 SPACE CENTER DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809153610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267334 | ||||||||
| FaxNumber: | 7195267749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2017 | ||||||||
| LastUpdateDate: | 10/02/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DHA PASS | ||||||||
| AuthorizedOfficialTelephone: | 2105366650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EVANS ARMY COMMUNITY HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | FU6493186 | CO | Y | Suppliers | Pharmacy |
No ID Information.