MEDICARE: ROCKY MOUNTAIN SPINE AND SPORT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	065	OTHER	CO	PHYSICAL THERAPY CLINIC

General Provider Information

NPI Number	:	1518172683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKY MOUNTAIN SPINE AND SPORT, LLC

Provider Business Mailing Address
First Line	:	4284 TRAIL BOSS DR
Second Line	:	#130
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-7521
Country	:	US
Telephone Number	:	303-663-8086
Fax Number	:	303-663-8289

Provider Business Practice Location Address
First Line	:	4284 TRAIL BOSS DR
Second Line	:	#130
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-7521
Country	:	US
Telephone Number	:	303-663-8086
Fax Number	:	303-663-8289

Authorized Official
Title or Position	:	ACCOUNTS AND OPERATIONS
Name	:	MRS. VALERIE JANE MUSICK
Credential	:
Telephone Number	:	303-792-7377

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	01/08/2008

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