Provider Demographics
NPI:1215342050
Name:COLORADO SPINE INSTITUTE PROFESSIONAL LLC
Entity type:Organization
Organization Name:COLORADO SPINE INSTITUTE PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-222-9745
Mailing Address - Street 1:4795 LARIMER PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-9021
Mailing Address - Country:US
Mailing Address - Phone:970-342-2220
Mailing Address - Fax:
Practice Address - Street 1:4795 LARIMER PKWY
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-9021
Practice Address - Country:US
Practice Address - Phone:970-342-2220
Practice Address - Fax:970-342-2220
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO SPINE INSTITUTE PROFESSIONAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-30
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies