Provider Demographics
NPI:1275728917
Name:BLUE SKY PAIN TREATMENT CENTER PC
Entity Type:Organization
Organization Name:BLUE SKY PAIN TREATMENT CENTER PC
Other - Org Name:BLUE SKY HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:LETOURNEAU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:303-980-1222
Mailing Address - Street 1:1360 S WADSWORTH BLVD
Mailing Address - Street 2:#208
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232
Mailing Address - Country:US
Mailing Address - Phone:303-980-1222
Mailing Address - Fax:303-980-1119
Practice Address - Street 1:1360 S WADSWORTH BLVD
Practice Address - Street 2:#208
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80232
Practice Address - Country:US
Practice Address - Phone:303-980-1222
Practice Address - Fax:303-980-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43062171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC804285Medicare PIN