Provider Demographics
NPI:1144618851
Name:FORT COLLINS FUNCTIONAL MOVEMENT INSTITUTE
Entity Type:Organization
Organization Name:FORT COLLINS FUNCTIONAL MOVEMENT INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ERIN
Authorized Official - Last Name:DEBORD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:970-492-5619
Mailing Address - Street 1:234 BISHOP ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-1708
Mailing Address - Country:US
Mailing Address - Phone:970-492-5619
Mailing Address - Fax:
Practice Address - Street 1:147 W OAK ST
Practice Address - Street 2:UNIT 111
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2824
Practice Address - Country:US
Practice Address - Phone:970-492-5619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-03
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8810261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy