Provider Demographics
NPI:1639405756
Name:COLORADO RIVER PAIN MANAGEMENT LLC
Entity Type:Organization
Organization Name:COLORADO RIVER PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SPILLANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-453-3267
Mailing Address - Street 1:1951 MESQUITE AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5746
Mailing Address - Country:US
Mailing Address - Phone:928-453-3267
Mailing Address - Fax:928-453-3276
Practice Address - Street 1:1951 MESQUITE AVE
Practice Address - Street 2:SUITE I
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5746
Practice Address - Country:US
Practice Address - Phone:928-453-3267
Practice Address - Fax:928-453-3276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26109261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG71877Medicare UPIN