Healthcare Provider Details

I. General information

NPI: 1053225599
Provider Name (Legal Business Name): COLE DILLON CRUCHON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

608 E PRINCETON AVE
GALLUP NM
87301-5042
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone: 918-606-5652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number230509
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: