MEDICARE: MR. RODNEY THOMAS GRAVENOR CSA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	SA0001088	CO
2	246ZS0410X	Surgical Technologist

General Provider Information

NPI Number	:	1386746881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RODNEY THOMAS GRAVENOR CSA

Provider Business Mailing Address
First Line	:	7202 BUCKINGHAM PL
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80130-4169
Country	:	US
Telephone Number	:	303-902-0423
Fax Number	:	720-221-7796

Provider Business Practice Location Address
First Line	:	7202 BUCKINGHAM PL
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80130-4169
Country	:	US
Telephone Number	:	303-902-0423
Fax Number	:	720-221-7796

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2006
Last Update Date	:	11/17/2014

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