Provider Demographics
NPI:1730781246
Name:NORTHEN COLORADO SPINE AND SPORT LLC
Entity type:Organization
Organization Name:NORTHEN COLORADO SPINE AND SPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:303-827-8785
Mailing Address - Street 1:3417 MOUNTAINWOOD LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-4135
Mailing Address - Country:US
Mailing Address - Phone:303-827-8785
Mailing Address - Fax:
Practice Address - Street 1:1905 W 8TH ST STE 116
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-5281
Practice Address - Country:US
Practice Address - Phone:303-827-8785
Practice Address - Fax:303-684-0481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty