Provider Demographics
NPI:1326174483
Name:DELTA PHYSICAL THERAPY AND SPORTS REHABILITATION PC
Entity Type:Organization
Organization Name:DELTA PHYSICAL THERAPY AND SPORTS REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:970-874-5747
Mailing Address - Street 1:185 STAFFORD LN
Mailing Address - Street 2:PO BOX 827
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-2229
Mailing Address - Country:US
Mailing Address - Phone:970-874-5747
Mailing Address - Fax:
Practice Address - Street 1:185 STAFFORD LN
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2229
Practice Address - Country:US
Practice Address - Phone:970-874-5747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO27956288Medicaid
CO27956288Medicaid