Individual
LAKE CRAWFORD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
777 BANNOCK ST # MC0108, DENVER, CO 80204-4507
(303) 602-5193
Mailing address
10800 E QUAIL CREEK CIR, DERBY, KS 67037-8381
(316) 640-8798
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
03/20/2023
Last updated
03/20/2023
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