Provider Demographics
NPI:1093728263
Name:HOMER, LAURA J (MPT, OCS)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:J
Last Name:HOMER
Suffix:
Gender:F
Credentials:MPT, OCS
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:J
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:PO BOX 2228
Mailing Address - Street 2:
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-2228
Mailing Address - Country:US
Mailing Address - Phone:970-728-8948
Mailing Address - Fax:970-728-8953
Practice Address - Street 1:750 WEST PACIFIC AVENUE
Practice Address - Street 2:
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435-2228
Practice Address - Country:US
Practice Address - Phone:970-728-8948
Practice Address - Fax:970-728-8953
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6388208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCD2333Medicare ID - Type Unspecified