Provider Demographics
NPI:1679766984
Name:COLORADO SPINE THERAPY, LLC
Entity type:Organization
Organization Name:COLORADO SPINE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STEFAN
Authorized Official - Middle Name:JH
Authorized Official - Last Name:VAN DUURSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:303-842-5614
Mailing Address - Street 1:P.O. BOX 21150
Mailing Address - Street 2:FLATIRONS PRACTICE MANAGEMENT
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-4150
Mailing Address - Country:US
Mailing Address - Phone:303-546-9158
Mailing Address - Fax:303-691-1142
Practice Address - Street 1:1385 S COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-3304
Practice Address - Country:US
Practice Address - Phone:303-842-5614
Practice Address - Fax:303-691-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO50122251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C810210Medicare PIN
1679766984Medicare UPIN