Provider Demographics
NPI:1942922000
Name:MONUMENT SPORT & SPINE LLC
Entity Type:Organization
Organization Name:MONUMENT SPORT & SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUMGARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-210-5933
Mailing Address - Street 1:609 NORTH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:GRAND JCT
Mailing Address - State:CO
Mailing Address - Zip Code:81501-7520
Mailing Address - Country:US
Mailing Address - Phone:970-242-7700
Mailing Address - Fax:
Practice Address - Street 1:609 NORTH AVE STE 1
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-7520
Practice Address - Country:US
Practice Address - Phone:970-242-7700
Practice Address - Fax:970-242-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-15
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
006D0914GOtherFULCRUM
MN093574OtherUHC
14426279OtherCAQH
MN1932762929Medicaid