Provider Demographics
NPI:1891240032
Name:ROCKY MOUNTAIN REHAB MEDICINE LLC
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN REHAB MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-378-6597
Mailing Address - Street 1:19153 EAST BRIARWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80016
Mailing Address - Country:US
Mailing Address - Phone:843-324-2406
Mailing Address - Fax:
Practice Address - Street 1:275 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6462
Practice Address - Country:US
Practice Address - Phone:720-378-6597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-17
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0054748208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty