Provider Demographics
NPI:1669645149
Name:INTERMOUNTAIN REHABILATATION ASSOC
Entity type:Organization
Organization Name:INTERMOUNTAIN REHABILATATION ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-227-0101
Mailing Address - Street 1:923 W COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-1517
Mailing Address - Country:US
Mailing Address - Phone:719-227-0101
Mailing Address - Fax:719-227-0303
Practice Address - Street 1:923 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1517
Practice Address - Country:US
Practice Address - Phone:719-227-0101
Practice Address - Fax:719-227-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30128174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01-301282Medicaid
COC77721Medicare PIN
COE91980Medicare UPIN