Basic Information
| Provider Information | |||||||||
| NPI: | 1316333115 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND MESA SPINE AND SPORT, LLC | ||||||||
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| OtherOrganizationName: | COLORADO INJURY AND PAIN SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7071 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436172700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198431370 | ||||||||
| FaxNumber: | 4198438402 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 W PARK DR | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815051469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702420162 | ||||||||
| FaxNumber: | 9702421097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2015 | ||||||||
| LastUpdateDate: | 04/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | HARMON | ||||||||
| AuthorizedOfficialFirstName: | LEILANI | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4198431370 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.