Healthcare Provider Details

I. General information

NPI: 1649657933
Provider Name (Legal Business Name): MILE HIGH SPINE AND PAIN CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7940 S UNIVERSITY BLVD SUITE 110
CENTENNIAL CO
80122-5104
US

IV. Provider business mailing address

7940 S UNIVERSITY BLVD SUITE 110
CENTENNIAL CO
80122-5104
US

V. Phone/Fax

Practice location:
  • Phone: 303-927-6181
  • Fax: 720-379-5827
Mailing address:
  • Phone: 303-927-6181
  • Fax: 720-379-5827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberDR,0026309
License Number StateCO

VIII. Authorized Official

Name: JAE HYEONG JEON
Title or Position: OWNER
Credential: P.T., D.P.T.
Phone: 720-401-8156