Healthcare Provider Details

I. General information

NPI: 1912622333
Provider Name (Legal Business Name): COMMUNITY SPECIALTY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2373 G RD STE 270
GRAND JCT CO
81505-1006
US

IV. Provider business mailing address

PO BOX 1727
GRAND JCT CO
81502-1727
US

V. Phone/Fax

Practice location:
  • Phone: 970-644-3800
  • Fax: 970-644-3946
Mailing address:
  • Phone: 970-644-3800
  • Fax: 970-644-3946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTIAN THOMAS
Title or Position: PRESIDENT/CEO
Credential:
Phone: 970-644-3011