Healthcare Provider Details

I. General information

NPI: 1174587521
Provider Name (Legal Business Name): PHILLIP GRADEN KLEINMAN MSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8607 BOHLEEN RD
PEYTON CO
80831
US

IV. Provider business mailing address

8607 BOHLEEN RD
PEYTON CO
80831
US

V. Phone/Fax

Practice location:
  • Phone: 719-495-2091
  • Fax:
Mailing address:
  • Phone: 719-495-2091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR37379
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: