Healthcare Provider Details

I. General information

NPI: 1265299424
Provider Name (Legal Business Name): JONATHAN DOUGLAS LANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JONATHAN LANG COLORADO ELITE OUTDO

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 06/14/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18983 E OREGON DR
AURORA CO
80017-5409
US

IV. Provider business mailing address

18983 E OREGON DR
AURORA CO
80017-5409
US

V. Phone/Fax

Practice location:
  • Phone: 720-712-8828
  • Fax:
Mailing address:
  • Phone: 720-712-8828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: