Provider Demographics
NPI:1295866770
Name:ROARING FORK PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:ROARING FORK PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:970-927-9319
Mailing Address - Street 1:1450 E VALLEY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-8352
Mailing Address - Country:US
Mailing Address - Phone:970-927-9319
Mailing Address - Fax:970-927-0168
Practice Address - Street 1:1450 E VALLEY RD
Practice Address - Street 2:SUITE 203
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-8352
Practice Address - Country:US
Practice Address - Phone:970-927-9319
Practice Address - Fax:970-927-0168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2906225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO066577Medicare ID - Type Unspecified