Healthcare Provider Details

I. General information

NPI: 1245938257
Provider Name (Legal Business Name): INDIVIDUAL CANVAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 REGENCY BLVD APT I
PUEBLO CO
81005-1831
US

IV. Provider business mailing address

46 REGENCY BLVD APT I
PUEBLO CO
81005-1831
US

V. Phone/Fax

Practice location:
  • Phone: 719-334-3123
  • Fax:
Mailing address:
  • Phone: 719-334-3123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: THERESA MARIE SANDOVAL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 719-334-3123