06D2025909 CLIA NUMBER - ROCKY MOUNTAIN PRIMARY CARE CLINIC

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Laboratory Demographics

CLIA Number: 06D2025909

Facility Name: ROCKY MOUNTAIN PRIMARY CARE CLINIC

Facility Address:
131 SOUTH MAIN ST SUITE 101
PUEBLO, CO
ZIP 81003
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Facility Phone Number: 719 924-9398

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1720385016

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	06D2025909
LAB Type	Practitioner Other
Facility Name	ROCKY MOUNTAIN PRIMARY CARE CLINIC
Street	131 SOUTH MAIN ST SUITE 101
City	PUEBLO
State	CO
ZIP	81003
Phone	719 924-9398
CertificateType	4
CertificateEffectiveDate	6/21/2023
CertificateExpirationDate	6/20/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024