Healthcare Provider Details

I. General information

NPI: 1518109909
Provider Name (Legal Business Name): JIMMY GLEN COLSON C.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2009
Last Update Date: 03/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S RANCHO DR #8B
LAS VEGAS NV
89106-4844
US

IV. Provider business mailing address

500 S RANCHO DR #8B
LAS VEGAS NV
89106-4844
US

V. Phone/Fax

Practice location:
  • Phone: 702-293-5502
  • Fax: 702-242-5572
Mailing address:
  • Phone: 702-293-5502
  • Fax: 702-242-5572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberH13-00347-2-143805
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: