Provider Demographics
NPI:1104395821
Name:COLOR COUNTRY PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:COLOR COUNTRY PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:APPLEGATE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:435-477-0095
Mailing Address - Street 1:1940 S BONITO WAY STE 190
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5618
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:
Practice Address - Street 1:450 E CLINIC WAY
Practice Address - Street 2:STE B
Practice Address - City:PAROWAN
Practice Address - State:UT
Practice Address - Zip Code:84761-8001
Practice Address - Country:US
Practice Address - Phone:435-559-2613
Practice Address - Fax:435-246-0352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy