Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2023-03-28
- Last updated
- 2023-03-28
Specialties
Licenses
- License CO
- 1662568
Location
- Practice location
- 11115 W. HWY 24, UNIT 2C
- City
- DIVIDE CO
- Postal code
- 808148081
- Phone
- 719-687-6416
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.