=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639405756
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLORADO RIVER PAIN MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2009
-----------------------------------------------------
Last Update Date | 11/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1951 MESQUITE AVE SUITE I
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-453-3267
-----------------------------------------------------
Fax | 928-453-3276
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1951 MESQUITE AVE SUITE I
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-453-3267
-----------------------------------------------------
Fax | 928-453-3276
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JUDITH A SPILLANE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-453-3267
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number | 26109
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------