Basic Information
| Provider Information | |||||||||
| NPI: | 1104907955 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY MOUNTAIN SPINE AND SPORT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10268 W CENTENNIAL RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801276423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039482999 | ||||||||
| FaxNumber: | 3039488667 | ||||||||
| Practice Location | |||||||||
| Address1: | 10268 W CENTENNIAL RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801276423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039482999 | ||||||||
| FaxNumber: | 3039488667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 01/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | MUSICK | ||||||||
| AuthorizedOfficialFirstName: | VALERIE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3037927377 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7124 | CO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 662341 | 01 | CO | BLUE CROSS BLUE SHIELD | OTHER |