Provider Demographics
NPI:1285884775
Name:FORT COLLINS PAIN TREATMENT CENTER INC
Entity type:Organization
Organization Name:FORT COLLINS PAIN TREATMENT CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ORRIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:CLEMENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-221-0565
Mailing Address - Street 1:1113 STONEY HILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1373
Mailing Address - Country:US
Mailing Address - Phone:970-221-0565
Mailing Address - Fax:970-221-0575
Practice Address - Street 1:1113 STONEY HILL RD STE A
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1373
Practice Address - Country:US
Practice Address - Phone:970-221-0565
Practice Address - Fax:970-221-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-22
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17195208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15322564Medicaid
CO15322564Medicaid