Healthcare Provider Details

I. General information

NPI: 1992235873
Provider Name (Legal Business Name): CRESTED BUTTE PEDIATRICS PROF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 06/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 6TH STREET SUITE 202
CRESTED BUTTE CO
81224
US

IV. Provider business mailing address

PO BOX 167
CRESTED BUTTE CO
81224-0167
US

V. Phone/Fax

Practice location:
  • Phone: 970-349-6606
  • Fax: 866-682-6309
Mailing address:
  • Phone: 970-349-6606
  • Fax: 866-682-6309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER M SANDERFORD
Title or Position: SOLE MEMBER
Credential: MD
Phone: 954-294-1963