Provider Demographics
NPI:1700220993
Name:GRAND MESA SPINE AND SPORT LLC
Entity Type:Organization
Organization Name:GRAND MESA SPINE AND SPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:419-843-1370
Mailing Address - Street 1:7071 W CENTRAL AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-2700
Mailing Address - Country:US
Mailing Address - Phone:419-843-1370
Mailing Address - Fax:419-843-1362
Practice Address - Street 1:201 WEST PARK DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505
Practice Address - Country:US
Practice Address - Phone:419-843-1370
Practice Address - Fax:419-843-8402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty