Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 1960 | CO |
NPI | 1427112002 |
---|---|
Provider Name | Keith Lundberg |
First Address | Montrose, CO 81401-3663 |
Second Address | Montrose, CO 81401-3663 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2006 |
Last Update Date | 08/07/2007 |