Healthcare Provider Details

I. General information

NPI: 1437418316
Provider Name (Legal Business Name): SAN JUAN RIVER REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 HOT SPRINGS BLVD
PAGOSA SPRINGS CO
81147-4002
US

IV. Provider business mailing address

PO BOX 2462
PAGOSA SPRINGS CO
81147-2462
US

V. Phone/Fax

Practice location:
  • Phone: 505-947-0112
  • Fax:
Mailing address:
  • Phone: 505-947-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7499
License Number StateCO

VIII. Authorized Official

Name: MR. DAVID WILLIAM DOLAN
Title or Position: OWNER
Credential: LMT
Phone: 505-947-0112