Provider Demographics
NPI:1063727444
Name:DR DEBRA IRIZARRY
Entity type:Organization
Organization Name:DR DEBRA IRIZARRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:IRIZARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-256-6600
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:CRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:81131-0749
Mailing Address - Country:US
Mailing Address - Phone:719-256-6600
Mailing Address - Fax:719-256-6600
Practice Address - Street 1:46 CAMINO BACA GRANDE
Practice Address - Street 2:102
Practice Address - City:CRESTONE
Practice Address - State:CO
Practice Address - Zip Code:81131
Practice Address - Country:US
Practice Address - Phone:719-256-6600
Practice Address - Fax:719-256-6600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO46205261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty