NPIMap

Organization Active NPI

Canon Professional Wellness Clinic LLC

  • Primary Care Nurse Practitioner
  • Canon City, CO
National Provider Identifier
1780384560
Registry record updated Feb 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Nurse PractitionerTaxonomy code 363LP2300X
Legal business name
CANON PROFESSIONAL WELLNESS CLINIC LLC
Practice address
730 Macon Ave
Canon City, CO 81212-3314
Phone
(719) 275-1618
NPI assigned
Mar 9, 2023
Last updated
Feb 19, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 19, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Leslie Nelson, APNNPI 1720721251
Title
Owner
Phone
(719) 285-5019

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Non-Surgical Family Planning Clinic/Center 261QF0050X
Primary Care Nurse Practitioner 363LP2300X Primary

Addresses

Primary practice location

730 Macon Ave
Canon City, CO 81212-3314

Mailing address

730 Macon Ave
Canon City, CO 81212-3314
Phone (719) 275-1618

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20231107002803 CO Part B Supplier - Clinic/Group Practice 1456708890 Receives reassigned benefits from 5 practitioners
Practice locations: Canon City, CO

National Provider Directory

National Provider Directory

Locations

730 Macon Ave
Canon City, CO 81212
Phone (719) 275-1618

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1678320000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708300800000",
    "number": "1780384560",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "730 MACON AVE",
            "city": "CANON CITY",
            "state": "CO",
            "postal_code": "812123314",
            "telephone_number": "719-275-1618"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "730 MACON AVE",
            "city": "CANON CITY",
            "state": "CO",
            "postal_code": "812123314",
            "telephone_number": "719-275-1618"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CANON PROFESSIONAL WELLNESS CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-03-09",
        "last_updated": "2024-02-19",
        "certification_date": "2024-02-19",
        "status": "A",
        "authorized_official_last_name": "NELSON",
        "authorized_official_first_name": "LESLIE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "719-285-5019",
        "authorized_official_credential": "APN"
    },
    "taxonomies": [
        {
            "code": "261QF0050X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Family Planning, Non-Surgical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Canon City, CO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.