Healthcare Provider Details

I. General information

NPI: 1558562488
Provider Name (Legal Business Name): LARRY KEITH CROCOMBE B.A.CACII
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 E 13TH ST
PUEBLO CO
81001-2940
US

IV. Provider business mailing address

2561 ELMWOOD LN
PUEBLO CO
81005-2703
US

V. Phone/Fax

Practice location:
  • Phone: 719-546-6666
  • Fax: 719-543-7764
Mailing address:
  • Phone: 719-564-4847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4136
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: