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General NPI Number Information
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NPI Number | 1639568058
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Entity Type | Organization
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Legal Business Name | BLACK MOUNTAIN ANESTHESIA GROUP
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Dates
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Enumeration Date | 01/22/2015
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Last Update Date | 01/22/2015
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Provider Practice Location Address
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Address Line | 750 HOSPITAL LOOP
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City | CRAIG
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State | CO
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Zip | 81625-8750
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Country | US
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Telephone | 970-824-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 1255 LECUYER DR
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City | CRAIG
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State | CO
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Zip | 81625-1438
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CRNA
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Name | MR. JOHN KEITH PRESCOTT
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Credential | MSNA
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Telephone | 918-850-5607
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 0205032
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License Number State | CO
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