Healthcare Provider Details

I. General information

NPI: 1508198565
Provider Name (Legal Business Name): VANNESS ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 FLINTRIDGE DR STE 101
COLORADO SPRINGS CO
80918-4254
US

IV. Provider business mailing address

4740 FLINTRIDGE DR STE 101
COLORADO SPRINGS CO
80918-4254
US

V. Phone/Fax

Practice location:
  • Phone: 719-510-6313
  • Fax: 719-358-7756
Mailing address:
  • Phone: 719-510-6313
  • Fax: 719-358-7756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number32854
License Number StateCO

VIII. Authorized Official

Name: RANDEE P VAN NESS
Title or Position: CEO
Credential: MS
Phone: 719-651-5102