=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699423921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERS EDGE PAIN SPECIALISTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2022
-----------------------------------------------------
Last Update Date | 07/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2249 BROADWAY STE 8
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81507-1157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-314-7094
-----------------------------------------------------
Fax | 970-314-7094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2033 BROADWAY
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81507-9710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-314-7094
-----------------------------------------------------
Fax | 970-314-7094
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR/NURSE PRACTITIONER
-----------------------------------------------------
Name | HEATHER JANAE SMITH
-----------------------------------------------------
Credential | DNP, APN, NP-C
-----------------------------------------------------
Telephone | 970-778-6323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------