Healthcare Provider Details

I. General information

NPI: 1700196631
Provider Name (Legal Business Name): SUSAN KAY YOUNG RD, CSO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 02/07/2021
Certification Date: 02/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2257 MAIN AVE
DURANGO CO
81301-4660
US

IV. Provider business mailing address

2257 MAIN AVE UNIT A
DURANGO CO
81301-4659
US

V. Phone/Fax

Practice location:
  • Phone: 970-946-0620
  • Fax: 970-422-1076
Mailing address:
  • Phone: 970-946-0620
  • Fax: 970-422-1076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1024929
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License Number1024929
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: