Provider Demographics
NPI:1851830640
Name:HIGHLANDS PAIN MANAGEMENT
Entity Type:Organization
Organization Name:HIGHLANDS PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC MS-REHAB MS-NUTRI
Authorized Official - Phone:760-449-7641
Mailing Address - Street 1:5950 S WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-5170
Mailing Address - Country:US
Mailing Address - Phone:720-515-8002
Mailing Address - Fax:303-741-2676
Practice Address - Street 1:5950 S WILLOW DR STE 200
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-5144
Practice Address - Country:US
Practice Address - Phone:720-515-8002
Practice Address - Fax:303-741-2676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR.0006922261QM2500X, 261QP2000X, 261QP3300X, 261QR0400X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care