Healthcare Provider Details

I. General information

NPI: 1881116754
Provider Name (Legal Business Name): DONALD FLYNN MT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

514 28 1/4 RD UNIT 4
GRAND JUNCTION CO
81501-4961
US

IV. Provider business mailing address

2458 THUNDER MOUNTAIN DR UNIT 412
GRAND JUNCTION CO
81505-4856
US

V. Phone/Fax

Practice location:
  • Phone: 970-644-5255
  • Fax: 970-644-5255
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0016901
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: