Provider Demographics
NPI:1023577764
Name:COLFAX, GARY LEE
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:COLFAX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-3051
Mailing Address - Country:US
Mailing Address - Phone:714-485-9778
Mailing Address - Fax:
Practice Address - Street 1:2390 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-3051
Practice Address - Country:US
Practice Address - Phone:714-485-9778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
95-3528706OtherCA