Provider Demographics
NPI:1144416215
Name:TRINIDAD PHYSICAL THERAPY AND SPORTS MEDICINE INC
Entity Type:Organization
Organization Name:TRINIDAD PHYSICAL THERAPY AND SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-846-1500
Mailing Address - Street 1:441 UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2542
Mailing Address - Country:US
Mailing Address - Phone:719-846-1500
Mailing Address - Fax:719-846-1501
Practice Address - Street 1:441 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2542
Practice Address - Country:US
Practice Address - Phone:719-846-1500
Practice Address - Fax:719-846-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5147BACA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03480585Medicaid
COC469278Medicare PIN
COP30758Medicare UPIN