Healthcare Provider Details

I. General information

NPI: 1922749514
Provider Name (Legal Business Name): JACK OCONNOR RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 TEJON ST APT 431
DENVER CO
80211-4484
US

IV. Provider business mailing address

3215 TEJON ST APT 431
DENVER CO
80211-4484
US

V. Phone/Fax

Practice location:
  • Phone: 479-616-6262
  • Fax:
Mailing address:
  • Phone: 479-616-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: