Healthcare Provider Details

I. General information

NPI: 1477188274
Provider Name (Legal Business Name): PHYSICAL MEDICINE OF THE ROCKIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 E BRIARWOOD AVE STE 100
CENTENNIAL CO
80112-3925
US

IV. Provider business mailing address

9025 GRANT ST STE 200
THORNTON CO
80229-4347
US

V. Phone/Fax

Practice location:
  • Phone: 719-465-0069
  • Fax:
Mailing address:
  • Phone: 719-465-0069
  • Fax: 720-930-4252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT J PRIMACK
Title or Position: PRESIDENT
Credential: DO
Phone: 719-457-6001