Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 6110 | CO |
NPI | 1598927402 |
---|---|
Provider Name | Dr. Clayton Richard Sullwold |
First Address | Durango, CO 81301-6545 |
Second Address | Durango, CO 81301-6545 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2008 |
Last Update Date | 01/07/2008 |