Healthcare Provider Details

I. General information

NPI: 1548009343
Provider Name (Legal Business Name): JACKSON SANGUILY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3827 N LAFAYETTE ST
DENVER CO
80205-5089
US

IV. Provider business mailing address

6 CARRIAGE WALK LN APT 342
SCARBOROUGH ME
04074-8296
US

V. Phone/Fax

Practice location:
  • Phone: 303-500-1518
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberQ212354
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: