Healthcare Provider Details

I. General information

NPI: 1871651638
Provider Name (Legal Business Name): SUMMIT EAGLE SPINE AND REHABILITATION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 PEAKONE DRIVE SUITE 390
FRISCO CO
80443
US

IV. Provider business mailing address

PO BOX 5089
FRISCO CO
80443-5089
US

V. Phone/Fax

Practice location:
  • Phone: 970-668-9471
  • Fax: 970-668-9473
Mailing address:
  • Phone: 970-668-9471
  • Fax: 970-668-9473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number33679
License Number StateCO

VIII. Authorized Official

Name: JULIE W COLLITON
Title or Position: OWNER
Credential: M.D.
Phone: 970-668-9471