Provider Demographics
NPI:1588210934
Name:ROCKY MOUNTAIN SPORTS MEDICINE INC.
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN SPORTS MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDLOCK GRANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-592-0112
Mailing Address - Street 1:12760 STROH RANCH WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-7507
Mailing Address - Country:US
Mailing Address - Phone:720-592-0112
Mailing Address - Fax:
Practice Address - Street 1:12760 STROH RANCH WAY STE 202
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-7507
Practice Address - Country:US
Practice Address - Phone:720-851-5420
Practice Address - Fax:720-851-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-12
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty