Provider Demographics
NPI:1255631776
Name:INNOVATIVE PAIN MEDICINE CENTER OF COLORADO - A PROFESSIONAL COMPANY
Entity type:Organization
Organization Name:INNOVATIVE PAIN MEDICINE CENTER OF COLORADO - A PROFESSIONAL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-663-2797
Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-0778
Mailing Address - Country:US
Mailing Address - Phone:303-663-2797
Mailing Address - Fax:303-663-2953
Practice Address - Street 1:4348 WOODLANDS BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-2800
Practice Address - Country:US
Practice Address - Phone:303-663-2797
Practice Address - Fax:303-663-2953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40692208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA 103673Medicare PIN