Provider Demographics
NPI:1588772305
Name:INTERMOUNTAIN REHAB ASSOC IN
Entity type:Organization
Organization Name:INTERMOUNTAIN REHAB ASSOC IN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:O
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-471-0727
Mailing Address - Street 1:559 E. PIKES PEAK AVE #100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3657
Mailing Address - Country:US
Mailing Address - Phone:719-471-0727
Mailing Address - Fax:719-471-2116
Practice Address - Street 1:559 E PIKES PEAK AVE #100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3657
Practice Address - Country:US
Practice Address - Phone:719-471-0727
Practice Address - Fax:719-471-2116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29593174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01-295930Medicaid
CO01-295930Medicaid
COC38081Medicare PIN