Provider Demographics
NPI:1710226600
Name:LONGMONT SPINE AND PHYSICAL MEDICINE, LLC
Entity Type:Organization
Organization Name:LONGMONT SPINE AND PHYSICAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-678-7170
Mailing Address - Street 1:451 21ST AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1421
Mailing Address - Country:US
Mailing Address - Phone:303-678-7170
Mailing Address - Fax:303-678-7134
Practice Address - Street 1:451 21ST AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1421
Practice Address - Country:US
Practice Address - Phone:303-678-7170
Practice Address - Fax:303-678-7134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27625208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO6742500001Medicare NSC