Healthcare Provider Details

I. General information

NPI: 1659640381
Provider Name (Legal Business Name): ROCKY MOUNTAIN NEURODIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2011
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 THOMES AVE STE 12550
CHEYENNE WY
82001-3527
US

IV. Provider business mailing address

1908 THOMES AVE STE 12550
CHEYENNE WY
82001-3527
US

V. Phone/Fax

Practice location:
  • Phone: 303-776-5298
  • Fax: 303-682-2785
Mailing address:
  • Phone: 303-776-5298
  • Fax: 303-682-2785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KIA CHURCHWELL
Title or Position: PAYER CREDENTIALING SPECIALIST
Credential:
Phone: 615-933-0792