Healthcare Provider Details

I. General information

NPI: 1043456007
Provider Name (Legal Business Name): MARK KETCHUM R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 12/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3061 E 109TH AVE
NORTHGLENN CO
80233-5475
US

IV. Provider business mailing address

3061 E 109TH AVE
NORTHGLENN CO
80233-5475
US

V. Phone/Fax

Practice location:
  • Phone: 720-271-0628
  • Fax: 303-953-1217
Mailing address:
  • Phone: 720-271-0628
  • Fax: 303-953-1217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number176755
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: