MEDICARE: RED CANYON NEUROLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204R00000X	Electrodiagnostic Medicine Physician

General Provider Information

NPI Number	:	1740884410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RED CANYON NEUROLOGY, LLC

Provider Business Mailing Address
First Line	:	4164 AUSTIN BLUFFS PKWY # 613
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-2928
Country	:	US
Telephone Number	:	720-443-6110
Fax Number	:

Provider Business Practice Location Address
First Line	:	4164 AUSTIN BLUFFS PKWY # 613
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-2928
Country	:	US
Telephone Number	:	720-443-6110
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	DOREEN SHINN
Credential	:
Telephone Number	:	720-443-6110

Provider Enumeration Date	:	11/24/2020
Last Update Date	:	11/24/2020

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