Healthcare Provider Details

I. General information

NPI: 1255631776
Provider Name (Legal Business Name): INNOVATIVE PAIN MEDICINE CENTER OF COLORADO - A PROFESSIONAL COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4348 WOODLANDS BLVD SUITE 230
CASTLE ROCK CO
80104-2800
US

IV. Provider business mailing address

PO BOX 778
CASTLE ROCK CO
80104-0778
US

V. Phone/Fax

Practice location:
  • Phone: 303-663-2797
  • Fax: 303-663-2953
Mailing address:
  • Phone: 303-663-2797
  • Fax: 303-663-2953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number40692
License Number StateCO

VIII. Authorized Official

Name: PATRICIA L LITTLE
Title or Position: PRESIDENT
Credential: MD
Phone: 303-663-2797