Provider Demographics
NPI:1114751153
Name:COLORADO SPRINGS DIRECT PRIMARY CARE
Entity type:Organization
Organization Name:COLORADO SPRINGS DIRECT PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CORNELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-362-5152
Mailing Address - Street 1:6510-A SOUTH ACADEMY BLVD
Mailing Address - Street 2:PMB 206
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906
Mailing Address - Country:US
Mailing Address - Phone:719-362-5152
Mailing Address - Fax:719-888-1592
Practice Address - Street 1:4711 OPUS DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-8718
Practice Address - Country:US
Practice Address - Phone:719-362-5152
Practice Address - Fax:719-888-1592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care