Healthcare Provider Details

I. General information

NPI: 1043759830
Provider Name (Legal Business Name): HIGHLANDS PAIN MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5950 S WILLOW DR STE 200
GREENWOOD VILLAGE CO
80111-5144
US

IV. Provider business mailing address

5950 S WILLOW DR STE 200
GREENWOOD VILLAGE CO
80111-5144
US

V. Phone/Fax

Practice location:
  • Phone: 720-515-8002
  • Fax: 303-741-2676
Mailing address:
  • Phone: 720-515-8002
  • Fax: 303-741-2676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberCHR.0006922
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberCHR.0006922
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License NumberCHR.0006922
License Number StateCO

VIII. Authorized Official

Name: DR. CLYDE JOHNSON
Title or Position: OWNER
Credential: DC MS-REHAB MS-NUTRI
Phone: 720-515-8002