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Registrant NPI Number: 1578884938

Individual Registrant:
Gender: M
Not Sole Proprietor

Location and contact information for practice:
267 6TH ST  MEEKER, CO 81641 US
Tel: 970-878-5112  Fax: 970-878-4315

Contact information for business:
Tel: 970-945-2241  Fax: 970-945-5523

Registration Information:
NPI: 1578884938
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y101Y00000XBehavioral Health & Social Service Providers
N101YS0200XBehavioral Health & Social Service Providers

Legacy codes, insurance codes and state license numbers:



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