Provider Demographics
NPI:1346596525
Name:COLORADO SPINE AND SPORTS CLINIC LLC
Entity Type:Organization
Organization Name:COLORADO SPINE AND SPORTS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-688-8855
Mailing Address - Street 1:1189 S PERRY ST
Mailing Address - Street 2:STE. 150
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-1959
Mailing Address - Country:US
Mailing Address - Phone:303-241-8827
Mailing Address - Fax:303-660-6692
Practice Address - Street 1:1189 S PERRY ST
Practice Address - Street 2:STE. 150
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1959
Practice Address - Country:US
Practice Address - Phone:303-241-8827
Practice Address - Fax:303-660-6692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6825111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty