Provider Demographics
NPI:1174642045
Name:PHYSICAL THERAPY CONNECTIONS, PC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY CONNECTIONS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, CSCS
Authorized Official - Phone:719-565-6678
Mailing Address - Street 1:58 GLEN ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2263
Mailing Address - Country:US
Mailing Address - Phone:719-565-6678
Mailing Address - Fax:719-561-0577
Practice Address - Street 1:58 GLEN ROYAL DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2174
Practice Address - Country:US
Practice Address - Phone:719-565-6678
Practice Address - Fax:719-561-0577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5835261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36630233Medicaid