Organization
ENT CLINIC OF PUEBLO PROF LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CHARLENE J HICKSON M.D. (OWNER/PARTNER)
(719) 544-3752
Entity
Organization
Contact information
Practice address
1304 N GRAND AVE, PUEBLO, CO 81003-2759
(719) 544-3752
(719) 542-1794
Mailing address
1304 N GRAND AVE, PUEBLO, CO 81003-2759
(719) 544-3752
(719) 542-1794
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
78674247
—
CO
Enumeration date
05/16/2006
Last updated
01/30/2008
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