Healthcare Provider Details

I. General information

NPI: 1679902001
Provider Name (Legal Business Name): MR. JASON KEITH HOLT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30999 COUNTY ROAD 15
LAS ANIMAS CO
81054-9499
US

IV. Provider business mailing address

1101 GRACE AVE
LA JUNTA CO
81050-3119
US

V. Phone/Fax

Practice location:
  • Phone: 719-662-1105
  • Fax: 719-456-0109
Mailing address:
  • Phone: 719-468-2734
  • Fax: 719-456-0109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberACB.0007699
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: