06D2173237 CLIA NUMBER - SOCO PRIMARY CARE CLINIC

Laboratory Demographics

CLIA Number: 06D2173237

Facility Name: SOCO PRIMARY CARE CLINIC

Facility Address:
1310 FORTINO BLVD, SUITE D
PUEBLO, CO
ZIP 81008
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Facility Phone Number: 719 582-1898

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1124677729

Taxonomy: 363LA2200X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	06D2173237
LAB Type	Practitioner Other
Facility Name	SOCO PRIMARY CARE CLINIC
Street	1310 FORTINO BLVD, SUITE D
City	PUEBLO
State	CO
ZIP	81008
Phone	719 582-1898
CertificateType	4
CertificateEffectiveDate	10/8/2023
CertificateExpirationDate	10/7/2025
FacilityType	Waiver

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