Basic Information
| Provider Information | |||||||||
| NPI: | 1932386562 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY MOUNTAIN SPINE & SPORT REHABILITATION STUDIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 991 SOUTHPARK DRIVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HIGHLANDS RANCH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037927377 | ||||||||
| FaxNumber: | 3037929077 | ||||||||
| Practice Location | |||||||||
| Address1: | 991 SOUTH PARK DRIVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037927377 | ||||||||
| FaxNumber: | 3037929077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2008 | ||||||||
| LastUpdateDate: | 01/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | KRELL | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PT, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3037927377 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROCKY MOUNTAIN SPINE & SPORT, LLC | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7064 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.