Healthcare Provider Details

I. General information

NPI: 1760754519
Provider Name (Legal Business Name): RANDALL M PFAFF JR. CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S MONACO PKWY 110
DENVER CO
80224-1878
US

IV. Provider business mailing address

1250 S MONACO PKWY 110
DENVER CO
80224-1878
US

V. Phone/Fax

Practice location:
  • Phone: 719-429-4531
  • Fax:
Mailing address:
  • Phone: 719-429-4531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number171W00000X
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: