Basic Information
| Provider Information | |||||||||
| NPI: | 1285679829 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLORADO PAIN AND REHABILITATION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1536 COLE BLVD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034238334 | ||||||||
| FaxNumber: | 3034561856 | ||||||||
| Practice Location | |||||||||
| Address1: | 1536 COLE BLVD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034238334 | ||||||||
| FaxNumber: | 3034561856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 09/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | HOWELL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3034238334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 0000000000 | CO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 18859020 | 05 | CO | MEDICAID |