1346586088 NPI number — JANDYCO, LLC

Table of content: (NPI 1346586088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346586088 NPI number — JANDYCO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JANDYCO, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346586088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
509 COLORADO AVE STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81004-2008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-214-2005
Provider Business Mailing Address Fax Number:
719-696-9862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 COLORADO AVE STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81004-2008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-696-9828
Provider Business Practice Location Address Fax Number:
719-696-9862
Provider Enumeration Date:
12/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
POLLOCK
Authorized Official First Name:
JAMIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/ PHYSICIAN
Authorized Official Telephone Number:
719-214-2005

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  44011 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0401X , with the licence number: 44011 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 29732581 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com