Healthcare Provider Details

I. General information

NPI: 1184449985
Provider Name (Legal Business Name): JASON DAVID CRANDALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4575 BYRD DR
LOVELAND CO
80538-7198
US

IV. Provider business mailing address

4575 BYRD DR
LOVELAND CO
80538-7198
US

V. Phone/Fax

Practice location:
  • Phone: 970-593-3300
  • Fax: 970-962-4901
Mailing address:
  • Phone: 970-593-3300
  • Fax: 970-962-4901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0335302
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: