Healthcare Provider Details

I. General information

NPI: 1104992296
Provider Name (Legal Business Name): WIND RIVER PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5873 HIGHLAND HILLS CIR
FORT COLLINS CO
80528-8941
US

IV. Provider business mailing address

5873 HIGHLAND HILLS CIR
FORT COLLINS CO
80528-8941
US

V. Phone/Fax

Practice location:
  • Phone: 970-420-9904
  • Fax:
Mailing address:
  • Phone: 970-420-9904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number39525
License Number StateCO

VIII. Authorized Official

Name: DR. JAMES ALAN DERRISAW
Title or Position: CEO
Credential: M.D.
Phone: 970-420-9904