Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 5512 | CO |
NPI | 1164509204 |
---|---|
Provider Name | Seth Allen |
First Address | Monument, CO 80132-3010 |
Second Address | Monument, CO 80132-7935 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T40849 | (02) | CO |