Healthcare Provider Details

I. General information

NPI: 1639131220
Provider Name (Legal Business Name): BRENT ALAN HASKELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 PHAY AVE
CANON CITY CO
81212-2302
US

IV. Provider business mailing address

1338 PHAY AVE
CANON CITY CO
81212-2302
US

V. Phone/Fax

Practice location:
  • Phone: 719-285-2646
  • Fax: 719-285-2647
Mailing address:
  • Phone: 719-285-2646
  • Fax: 719-285-2647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number34749
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: