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General NPI Number Information
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NPI Number | 1427756519
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Entity Type | Individual
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Provider Name | TEAGAN CLARK BALLINLEE DRAKE LMT
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Gender | Male
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Dates
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Enumeration Date | 02/20/2023
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Last Update Date | 02/20/2023
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Provider Practice Location Address
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Address Line | 2130 MOUNTAIN VIEW AVE STE 205
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City | LONGMONT
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State | CO
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Zip | 80501-3177
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Country | US
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Telephone | 303-835-7882
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Fax |
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Provider Business Mailing Address
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Address Line | 1065 REDBUD CIR
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City | LONGMONT
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State | CO
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Zip | 80503-7351
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Country | US
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Telephone | 469-426-5542
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 0025597
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License Number State | CO
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