Provider Demographics
NPI:1679041735
Name:STRAUB, JOHN RUSSELL
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:STRAUB
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 1:200 COMANCHE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-1651
Mailing Address - Country:US
Mailing Address - Phone:719-749-8251
Mailing Address - Fax:
Practice Address - Street 1:200 COMANCHE VILLAGE DR
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-1651
Practice Address - Country:US
Practice Address - Phone:719-749-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00020982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer