Healthcare Provider Details

I. General information

NPI: 1386060689
Provider Name (Legal Business Name): COLORADO SPINE AND SPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 W SOUTH BOULDER RD SUITE 1
LOUISVILLE CO
80027-1196
US

IV. Provider business mailing address

335 W SOUTH BOULDER RD SUITE 1
LOUISVILLE CO
80027-1196
US

V. Phone/Fax

Practice location:
  • Phone: 303-604-4358
  • Fax:
Mailing address:
  • Phone: 303-604-4358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5130
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5684
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9340
License Number StateCO

VIII. Authorized Official

Name: DR. MAUREEN THOMM
Title or Position: OWNER
Credential: D.C.
Phone: 303-604-4358