Provider Demographics
NPI:1154971661
Name:OLD COLORADO CITY WELLNESS PLLC
Entity type:Organization
Organization Name:OLD COLORADO CITY WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:ELENE
Authorized Official - Last Name:SMOTHERS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, BC
Authorized Official - Phone:719-473-2368
Mailing Address - Street 1:2020 W COLORADO AVE # 303
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-3882
Mailing Address - Country:US
Mailing Address - Phone:719-473-2368
Mailing Address - Fax:719-473-4581
Practice Address - Street 1:2020 W COLORADO AVE # 303
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3882
Practice Address - Country:US
Practice Address - Phone:719-473-2368
Practice Address - Fax:719-473-4581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-17
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty