Provider Demographics
NPI:1043602246
Name:FORT COLLINS SPINE LLC
Entity Type:Organization
Organization Name:FORT COLLINS SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-818-2791
Mailing Address - Street 1:2021 BATTLECREEK DR
Mailing Address - Street 2:UNIT D
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-5119
Mailing Address - Country:US
Mailing Address - Phone:970-286-2393
Mailing Address - Fax:970-825-5920
Practice Address - Street 1:2021 BATTLECREEK DR
Practice Address - Street 2:UNIT D
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-5119
Practice Address - Country:US
Practice Address - Phone:970-286-2393
Practice Address - Fax:970-825-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO53745207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty