Provider Demographics
NPI:1437418316
Name:SAN JUAN RIVER REHABILITATION LLC
Entity type:Organization
Organization Name:SAN JUAN RIVER REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:505-947-0112
Mailing Address - Street 1:PO BOX 2462
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-2462
Mailing Address - Country:US
Mailing Address - Phone:505-947-0112
Mailing Address - Fax:
Practice Address - Street 1:250 HOT SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-4002
Practice Address - Country:US
Practice Address - Phone:505-947-0112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7499225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty