Healthcare Provider Details

I. General information

NPI: 1043602246
Provider Name (Legal Business Name): FORT COLLINS SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 BATTLECREEK DR UNIT D
FORT COLLINS CO
80528-5119
US

IV. Provider business mailing address

2021 BATTLECREEK DR UNIT D
FORT COLLINS CO
80528-5119
US

V. Phone/Fax

Practice location:
  • Phone: 970-286-2393
  • Fax: 970-825-5920
Mailing address:
  • Phone: 970-286-2393
  • Fax: 970-825-5920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number53745
License Number StateCO

VIII. Authorized Official

Name: JOHN RAY
Title or Position: OWNER
Credential: MD
Phone: 970-818-2791