Provider Demographics
NPI:1316060999
Name:ROCKY MOUNTAIN PAIN RELIEF CENTER
Entity type:Organization
Organization Name:ROCKY MOUNTAIN PAIN RELIEF CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DEWEY
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:303-776-5700
Mailing Address - Street 1:PO BOX 926
Mailing Address - Street 2:
Mailing Address - City:NIWOT
Mailing Address - State:CO
Mailing Address - Zip Code:80544-0926
Mailing Address - Country:US
Mailing Address - Phone:303-776-5700
Mailing Address - Fax:303-776-5701
Practice Address - Street 1:630 15TH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-2700
Practice Address - Country:US
Practice Address - Phone:303-776-5700
Practice Address - Fax:303-776-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40660208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC803292Medicare PIN
C71589Medicare UPIN