Provider Demographics
NPI:1942708326
Name:LUCKY BREAK ORTHOPEDICS, PC
Entity Type:Organization
Organization Name:LUCKY BREAK ORTHOPEDICS, PC
Other - Org Name:PINNACLE ORTHOPEDICS AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ELFENBEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-672-1980
Mailing Address - Street 1:PO BOX 1627
Mailing Address - Street 2:
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224-1627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 N TAYLOR ST
Practice Address - Street 2:SUITE 200 A
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2648
Practice Address - Country:US
Practice Address - Phone:970-672-1980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO56343261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7693530001OtherMEDICARE NSC
CODR.0056343Medicaid