Healthcare Provider Details

I. General information

NPI: 1477386936
Provider Name (Legal Business Name): DOUGREY DARWIN VON NEUENSCHWANDER MT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3676 PARKER BLVD
PUEBLO CO
81008-2212
US

IV. Provider business mailing address

PO BOX 9000
PUEBLO CO
81008-9000
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-1804
  • Fax: 719-553-2223
Mailing address:
  • Phone: 719-553-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0026778
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: