Provider Demographics
NPI:1083665657
Name:SPINE COLORADO PC
Entity Type:Organization
Organization Name:SPINE COLORADO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REIMBURSEMENT ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:KATYA
Authorized Official - Middle Name:
Authorized Official - Last Name:LICCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:970-375-3661
Mailing Address - Street 1:1 MERCADO ST
Mailing Address - Street 2:STE 200
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7300
Mailing Address - Country:US
Mailing Address - Phone:970-382-9500
Mailing Address - Fax:970-375-0007
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:STE 200
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7300
Practice Address - Country:US
Practice Address - Phone:970-382-9500
Practice Address - Fax:970-375-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC69008Medicare PIN