Basic Information
| Provider Information | |||||||||
| NPI: | 1518172683 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY MOUNTAIN SPINE AND SPORT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4284 TRAIL BOSS DR | ||||||||
| Address2: | #130 | ||||||||
| City: | CASTLE ROCK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801047521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036638086 | ||||||||
| FaxNumber: | 3036638289 | ||||||||
| Practice Location | |||||||||
| Address1: | 4284 TRAIL BOSS DR | ||||||||
| Address2: | #130 | ||||||||
| City: | CASTLE ROCK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801047521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036638086 | ||||||||
| FaxNumber: | 3036638289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | MUSICK | ||||||||
| AuthorizedOfficialFirstName: | VALERIE | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNTS AND OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3037927377 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 065 | 01 | CO | PHYSICAL THERAPY CLINIC | OTHER |