Individual
MR. EDGAR CARL DE VAN III
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CAC II
Contact information
Practice address
615 RUSSELL AVE, WALSENBURG, CO 81089-2127
(719) 738-2076
Mailing address
206 W 3RD ST, WALSENBURG, CO 81089-1904
(719) 738-1082
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
6541
CO
Other
Enumeration date
06/04/2007
Last updated
07/08/2007
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