Healthcare Provider Details

I. General information

NPI: 1720142151
Provider Name (Legal Business Name): BLAIR GRANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6465 GREENWOOD PLAZA BLVD SUITE 300
CENTENNIAL CO
80111-4905
US

IV. Provider business mailing address

5335 FLYING S LN
COLORADO SPRINGS CO
80915-2400
US

V. Phone/Fax

Practice location:
  • Phone: 303-267-3596
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number122525
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: