Healthcare Provider Details

I. General information

NPI: 1083665657
Provider Name (Legal Business Name): SPINE COLORADO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCADO ST STE 200
DURANGO CO
81301-7300
US

IV. Provider business mailing address

1 MERCADO ST STE 200
DURANGO CO
81301-7300
US

V. Phone/Fax

Practice location:
  • Phone: 970-382-9500
  • Fax: 970-375-0007
Mailing address:
  • Phone: 970-382-9500
  • Fax: 970-375-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: KATYA LICCIARDI
Title or Position: REIMBURSEMENT ANALYST
Credential: CPC
Phone: 970-375-3661