Provider Demographics
NPI:1932386562
Name:ROCKY MOUNTAIN SPINE & SPORT REHABILITATION STUDIO
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN SPINE & SPORT REHABILITATION STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT, OWNER
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:303-792-7377
Mailing Address - Street 1:991 SOUTHPARK DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80126
Mailing Address - Country:US
Mailing Address - Phone:303-792-7377
Mailing Address - Fax:303-792-9077
Practice Address - Street 1:991 SOUTH PARK DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120
Practice Address - Country:US
Practice Address - Phone:303-792-7377
Practice Address - Fax:303-792-9077
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROCKY MOUNTAIN SPINE & SPORT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7064225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO477678Medicare PIN