Healthcare Provider Details

I. General information

NPI: 1801208236
Provider Name (Legal Business Name): COLORADO SPINE INSTITUTE PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4795 LARIMER PKWY
JOHNSTOWN CO
80534-9021
US

IV. Provider business mailing address

4795 LARIMER PKWY
JOHNSTOWN CO
80534-9021
US

V. Phone/Fax

Practice location:
  • Phone: 970-342-2220
  • Fax: 970-342-2221
Mailing address:
  • Phone: 970-342-2220
  • Fax: 970-342-2221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number30264
License Number StateCO

VIII. Authorized Official

Name: EDWARD JEFFREY DONNER
Title or Position: OWNER
Credential: MD
Phone: 970-342-2220