Provider Demographics
NPI:1114537438
Name:CONNECT MOVEMENT CENTER LLC
Entity Type:Organization
Organization Name:CONNECT MOVEMENT CENTER LLC
Other - Org Name:CONNECT MOVEMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:CHEN
Authorized Official - Last Name:BENTIVOLIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-838-4083
Mailing Address - Street 1:PO BOX 1945
Mailing Address - Street 2:
Mailing Address - City:FAIRPLAY
Mailing Address - State:CO
Mailing Address - Zip Code:80440-1945
Mailing Address - Country:US
Mailing Address - Phone:719-293-5198
Mailing Address - Fax:
Practice Address - Street 1:540 FRONT STREET
Practice Address - Street 2:
Practice Address - City:FAIRPLAY
Practice Address - State:CO
Practice Address - Zip Code:80440
Practice Address - Country:US
Practice Address - Phone:630-881-7866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-01
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000186967Medicaid