Provider Demographics
NPI:1386775781
Name:TRAUMATIC BRAIN INJURY OF SOUTHERN COLORADO, PC
Entity type:Organization
Organization Name:TRAUMATIC BRAIN INJURY OF SOUTHERN COLORADO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:719-520-1102
Mailing Address - Street 1:402 W BIJOU ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-1309
Mailing Address - Country:US
Mailing Address - Phone:719-520-1102
Mailing Address - Fax:719-302-6686
Practice Address - Street 1:4117 N ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2009
Practice Address - Country:US
Practice Address - Phone:719-520-1102
Practice Address - Fax:719-302-6686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty