Healthcare Provider Details

I. General information

NPI: 1790290179
Provider Name (Legal Business Name): JEFFREY D RYKHUS LAB TECHNICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 WETZEL AVE BLDG 815
FORT CARSON CO
80913-4095
US

IV. Provider business mailing address

1631 WETZEL AVE BLDG 815
FORT CARSON CO
80913-4095
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-5537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: