Basic Information
| Provider Information | |||||||||
| NPI: | 1346646999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY MOUNTAIN REHABILITATION LLC | ||||||||
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| OtherOrganizationName: | ROCKY MOUNTAIN RESTORATIVE MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2233 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707650818 | ||||||||
| FaxNumber: | 9704978410 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 HILLCREST PLAZA WAY | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814015876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706157223 | ||||||||
| FaxNumber: | 9706157226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2014 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FARAGHER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER & PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7203206616 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 83828079 | 05 | CO | MEDICAID |