Provider Demographics
NPI:1992790141
Name:ADVANCED SPINE & REHABILITATION
Entity type:Organization
Organization Name:ADVANCED SPINE & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:BARCLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-204-9635
Mailing Address - Street 1:343 W DRAKE RD
Mailing Address - Street 2:STE 102
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-6317
Mailing Address - Country:US
Mailing Address - Phone:970-204-9635
Mailing Address - Fax:970-204-9730
Practice Address - Street 1:343 W DRAKE RD
Practice Address - Street 2:STE 102
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-6317
Practice Address - Country:US
Practice Address - Phone:970-204-9635
Practice Address - Fax:970-204-9730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC442258Medicare ID - Type Unspecified