Provider Demographics
NPI:1386728285
Name:DURANGO SPORTS CLUB, INC.
Entity type:Organization
Organization Name:DURANGO SPORTS CLUB, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-385-6969
Mailing Address - Street 1:1600 FLORIDA RD
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-6836
Mailing Address - Country:US
Mailing Address - Phone:970-385-6969
Mailing Address - Fax:970-247-7810
Practice Address - Street 1:1600 FLORIDA RD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-6836
Practice Address - Country:US
Practice Address - Phone:970-385-6969
Practice Address - Fax:970-247-7810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO37026OtherBLUE CROSS BLUE SHIELD
CP4003Medicare UPIN
COP4003Medicare ID - Type Unspecified