Healthcare Provider Details

I. General information

NPI: 1427712967
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL GROUP GRAND JUNCTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 STAFFORD LN
DELTA CO
81416-2243
US

IV. Provider business mailing address

500 ELDORADO BLVD STE 6300
BROOMFIELD CO
80021-3422
US

V. Phone/Fax

Practice location:
  • Phone: 970-298-6005
  • Fax: 970-298-7138
Mailing address:
  • Phone: 303-272-0566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JON MCDANIEL
Title or Position: VP FINANCE MEDICAL GROUPS
Credential:
Phone: 303-272-0231