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General NPI Number Information
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NPI Number | 1104363472
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Entity Type | Organization
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Legal Business Name | DISTILLED DESIGN WORKS LLC
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Dates
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Enumeration Date | 01/25/2017
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Last Update Date | 01/25/2017
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Provider Practice Location Address
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Address Line | 832 N CREST DR
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City | GRAND JUNCTION
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State | CO
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Zip | 81506-8781
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Country | US
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Telephone | 970-712-1435
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Fax | 970-243-3968
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Provider Business Mailing Address
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Address Line | 832 N CREST DR
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City | GRAND JUNCTION
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State | CO
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Zip | 81506-8781
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Country | US
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Telephone | 970-712-1435
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Fax | 970-243-3968
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Authorized Official
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Title or Position | OWNER
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Name | ROBERT G DITTMER
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Credential |
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Telephone | 970-712-1435
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171WV0202X
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Taxonomy Name | Vehicle Modifications Contractor
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License Number |
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License Number State | CO
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