Provider Demographics
NPI:1124677729
Name:SOCO PRIMARY CARE CLINIC
Entity type:Organization
Organization Name:SOCO PRIMARY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BETTS
Authorized Official - Suffix:
Authorized Official - Credentials:NP, AGNP-C
Authorized Official - Phone:719-582-1898
Mailing Address - Street 1:1310 FORTINO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 FORTINO BLVD STE D
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2076
Practice Address - Country:US
Practice Address - Phone:719-582-1898
Practice Address - Fax:719-621-4098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty