Provider Demographics
NPI:1285745802
Name:ASPEN CLUB SPORTS MEDICINE INST
Entity type:Organization
Organization Name:ASPEN CLUB SPORTS MEDICINE INST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-920-5827
Mailing Address - Street 1:1450 CRYSTAL LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-2255
Mailing Address - Country:US
Mailing Address - Phone:970-920-5827
Mailing Address - Fax:970-925-4879
Practice Address - Street 1:1450 CRYSTAL LAKE ROAD
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-2255
Practice Address - Country:US
Practice Address - Phone:970-920-5827
Practice Address - Fax:970-925-4879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO342708Medicare ID - Type Unspecified