Provider Demographics
NPI:1376157909
Name:SPINE WEST A PROFESSIONAL LLC
Entity Type:Organization
Organization Name:SPINE WEST A PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-494-7773
Mailing Address - Street 1:5387 MANHATTAN CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4283
Mailing Address - Country:US
Mailing Address - Phone:303-494-7773
Mailing Address - Fax:303-494-1104
Practice Address - Street 1:705 MARKETPLACE PLZ
Practice Address - Street 2:
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487-1800
Practice Address - Country:US
Practice Address - Phone:303-494-7773
Practice Address - Fax:303-494-1104
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPINE WEST A PROFESSIONAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty