Provider Demographics
NPI:1770015059
Name:COLGROVE, IRMA G
Entity Type:Individual
Prefix:MRS
First Name:IRMA
Middle Name:G
Last Name:COLGROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9192 CAMINO LAGO VIS
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977
Mailing Address - Country:US
Mailing Address - Phone:619-954-1105
Mailing Address - Fax:
Practice Address - Street 1:9102 CAMINO LAGO VIS
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-6425
Practice Address - Country:US
Practice Address - Phone:619-954-1105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00455387376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide