Provider Demographics
NPI:1457444085
Name:FORM AND FITNESS PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:FORM AND FITNESS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:303-404-9494
Mailing Address - Street 1:13606 XAVIER LANE
Mailing Address - Street 2:STE C
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020
Mailing Address - Country:US
Mailing Address - Phone:303-404-9494
Mailing Address - Fax:303-404-2252
Practice Address - Street 1:13606 XAVIER LANE
Practice Address - Street 2:STE C
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020
Practice Address - Country:US
Practice Address - Phone:303-404-9494
Practice Address - Fax:303-404-2252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6265261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========Medicare UPIN
CO534748Medicare ID - Type Unspecified