Provider Demographics
NPI:1952789059
Name:GRAND MESA SPINE AND SPORT, LLC
Entity type:Organization
Organization Name:GRAND MESA SPINE AND SPORT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEILANI
Authorized Official - Middle Name:
Authorized Official - Last Name:HARMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-843-1370
Mailing Address - Street 1:7071 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-2700
Mailing Address - Country:US
Mailing Address - Phone:419-843-1370
Mailing Address - Fax:419-843-8402
Practice Address - Street 1:201 W PARK DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1469
Practice Address - Country:US
Practice Address - Phone:970-242-0162
Practice Address - Fax:970-242-1097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies