1134270085 NPI number — RED LADY SPINE & SPORTS PHYSICAL THERAPY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134270085 NPI number — RED LADY SPINE & SPORTS PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED LADY SPINE & SPORTS PHYSICAL THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134270085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESTED BUTTE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81224-1117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-349-2772
Provider Business Mailing Address Fax Number:
970-349-0459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
427 BELLEVIEW AVE.
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
CRESTED BUTTE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81224-1117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-349-2772
Provider Business Practice Location Address Fax Number:
970-349-0459
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
SHELLEY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
97803492772

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3665 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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