Healthcare Provider Details

I. General information

NPI: 1194989913
Provider Name (Legal Business Name): RICHARD A GROSSMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCADO ST STE 105
DURANGO CO
81301-7311
US

IV. Provider business mailing address

PO BOX 2674
DURANGO CO
81302-2674
US

V. Phone/Fax

Practice location:
  • Phone: 970-259-7679
  • Fax: 970-382-0784
Mailing address:
  • Phone: 970-259-7679
  • Fax: 970-382-0784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number20447
License Number StateCO

VIII. Authorized Official

Name: MS. MELODY A WARREN
Title or Position: BILLER
Credential:
Phone: 970-259-7679