Provider Demographics
NPI:1730319542
Name:ROCKY MOUNTAIN SPINE & SPORT, LLC
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN SPINE & SPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:KRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:303-792-7377
Mailing Address - Street 1:9995 PARK MEADOWS DRIVE
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-9995
Mailing Address - Country:US
Mailing Address - Phone:303-792-2334
Mailing Address - Fax:303-792-3340
Practice Address - Street 1:9995 PARK MEADOWS DRIVE
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-9995
Practice Address - Country:US
Practice Address - Phone:303-792-2334
Practice Address - Fax:303-792-3340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7115225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC477678Medicare UPIN