Healthcare Provider Details

I. General information

NPI: 1588210934
Provider Name (Legal Business Name): ROCKY MOUNTAIN SPORTS MEDICINE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12760 STROH RANCH WAY STE 202
PARKER CO
80134-7507
US

IV. Provider business mailing address

12760 STROH RANCH WAY STE 202
PARKER CO
80134-7507
US

V. Phone/Fax

Practice location:
  • Phone: 720-851-5420
  • Fax: 720-851-5801
Mailing address:
  • Phone: 720-592-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KATHRYN VIDLOCK GRANLEY
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 720-592-0112