Healthcare Provider Details

I. General information

NPI: 1346225539
Provider Name (Legal Business Name): GRANT ALLEN HURLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19021 US HIGHWAY 285
LA JARA CO
81140
US

IV. Provider business mailing address

19021 US HIGHWAY 285
LA JARA CO
81140
US

V. Phone/Fax

Practice location:
  • Phone: 719-274-5121
  • Fax: 719-274-6003
Mailing address:
  • Phone: 719-274-5121
  • Fax: 719-274-6003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number24232
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: