06D2161861 CLIA NUMBER - ADVANCED PRACTICE HEADACHE & PRIMARY CARE CLINIC

Laboratory Demographics

CLIA Number: 06D2161861

Facility Name: ADVANCED PRACTICE HEADACHE & PRIMARY CARE CLINIC

Facility Address:
1128 EAGLERIDGE BLVD
PUEBLO, CO
ZIP 81008
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Facility Phone Number: 719 778-1414

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1013490259

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	06D2161861
LAB Type	Practitioner Other
Facility Name	ADVANCED PRACTICE HEADACHE & PRIMARY CARE CLINIC
Street	1128 EAGLERIDGE BLVD
City	PUEBLO
State	CO
ZIP	81008
Phone	719 778-1414
CertificateType	4
CertificateEffectiveDate	2/12/2023
CertificateExpirationDate	2/11/2025
FacilityType	Waiver

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