Basic Information
| Provider Information | |||||||||
| NPI: | 1710562012 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3468 | ||||||||
| Address2: | |||||||||
| City: | ESTES PARK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805173468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039953541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 421 21ST AVE | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805011469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037729600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2021 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 854438 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.