Provider Demographics
NPI:1215585682
Name:LOREDO, VIOLETA (PTA)
Entity Type:Individual
Prefix:
First Name:VIOLETA
Middle Name:
Last Name:LOREDO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1637 29TH AVENUE PL
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6822
Mailing Address - Country:US
Mailing Address - Phone:970-380-8906
Mailing Address - Fax:
Practice Address - Street 1:1637 29TH AVENUE PL
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6822
Practice Address - Country:US
Practice Address - Phone:970-356-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0012184225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0012184Medicaid