Provider Demographics
NPI:1881810612
Name:SAMMONS, TROY E (MACOM, LAC)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:E
Last Name:SAMMONS
Suffix:
Gender:M
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 S AVENIDA DEL ORO W
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-6191
Mailing Address - Country:US
Mailing Address - Phone:719-250-4090
Mailing Address - Fax:
Practice Address - Street 1:115 W 11TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2801
Practice Address - Country:US
Practice Address - Phone:719-544-3326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO567171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO611913700OtherWORKERS COMPENSATION ID
CO651493OtherANTHEM BC BS