1447643127 NPI number — COLORADO INSTITUTE FOR PAIN MANAGEMENT LLC

Table of content: (NPI 1447643127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447643127 NPI number — COLORADO INSTITUTE FOR PAIN MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORADO INSTITUTE FOR PAIN MANAGEMENT LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447643127
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3910 S CAREFREE CIR STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80917-3053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-599-5753
Provider Business Mailing Address Fax Number:
719-599-5817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3910 S CAREFREE CIR STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80917-3053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-599-5753
Provider Business Practice Location Address Fax Number:
719-599-5817
Provider Enumeration Date:
03/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
TYLER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
MASON
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
719-599-5753

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  30232 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X , with the licence number: 30232 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103200300 . This is a "DEPARTMENT OF LABOR PROVIDER ID" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 4489508 . This is a "CIGNA PROVIDER ID" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 4489508 . This is a "AETNA PROVIDER ID" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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