Provider Demographics
NPI:1124441084
Name:COMFORT CARE FAMILY PRACTICE, INC.
Entity type:Organization
Organization Name:COMFORT CARE FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIESCAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-510-0957
Mailing Address - Street 1:5799 STETSON HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-4223
Mailing Address - Country:US
Mailing Address - Phone:719-471-2273
Mailing Address - Fax:719-380-0228
Practice Address - Street 1:6908 MESA RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-1533
Practice Address - Country:US
Practice Address - Phone:719-471-2273
Practice Address - Fax:719-380-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2024-02-15
Deactivation Date:2024-01-25
Deactivation Code:
Reactivation Date:2024-02-14
Provider Licenses
StateLicense IDTaxonomies
CO49109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46324275Medicaid
CO46324275Medicaid