Provider Demographics
NPI:1295067866
Name:ROCKY MOUNTAIN SPINE & SPORT, LLC
Entity type:Organization
Organization Name:ROCKY MOUNTAIN SPINE & SPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNDER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:KRELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:303-702-7377
Mailing Address - Street 1:15530 W 64TH AVE
Mailing Address - Street 2:UNIT E-F
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80007-6874
Mailing Address - Country:US
Mailing Address - Phone:303-424-4589
Mailing Address - Fax:303-424-4632
Practice Address - Street 1:15530 W 64TH AVE
Practice Address - Street 2:UNIT E-F
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80007-6874
Practice Address - Country:US
Practice Address - Phone:303-424-4589
Practice Address - Fax:303-424-4632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10646225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC477678OtherPHYSICAL THERAPY
COC477678Medicare PIN