Provider Demographics
NPI:1306024708
Name:COLORADO SPINE PAIN & SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:COLORADO SPINE PAIN & SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:NIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-692-5550
Mailing Address - Street 1:1437 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4324
Mailing Address - Country:US
Mailing Address - Phone:970-692-5550
Mailing Address - Fax:970-692-5561
Practice Address - Street 1:1437 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4324
Practice Address - Country:US
Practice Address - Phone:970-495-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40977208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19823738Medicaid
CO19823738Medicaid
COCOB4002Medicare PIN