Basic Information
| Provider Information | |||||||||
| NPI: | 1700220993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND MESA SPINE AND SPORT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7071 W CENTRAL AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436172700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198431370 | ||||||||
| FaxNumber: | 4198431362 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 WEST PARK DR | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198431370 | ||||||||
| FaxNumber: | 4198438402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2013 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | JAMES | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | GEORGE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4198431370 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.