Healthcare Provider Details

I. General information

NPI: 1710562012
Provider Name (Legal Business Name): WESLEY SCOTT ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 21ST AVE
LONGMONT CO
80501-1469
US

IV. Provider business mailing address

PO BOX 3468
ESTES PARK CO
80517-3468
US

V. Phone/Fax

Practice location:
  • Phone: 303-772-9600
  • Fax:
Mailing address:
  • Phone: 303-995-3541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number854438
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: