Provider Demographics
NPI:1235592460
Name:MAINSTAY PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:MAINSTAY PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALOUF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-544-2307
Mailing Address - Street 1:1030 CENTRE AVE
Mailing Address - Street 2:STE B
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1849
Mailing Address - Country:US
Mailing Address - Phone:406-544-2307
Mailing Address - Fax:970-360-7021
Practice Address - Street 1:1030 CENTRE AVE
Practice Address - Street 2:STE B
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1849
Practice Address - Country:US
Practice Address - Phone:406-544-2307
Practice Address - Fax:970-360-7021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty