Provider Demographics
NPI:1467753483
Name:GAIA PHYSICAL THERAPY
Entity Type:Organization
Organization Name:GAIA PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:HAVICE
Authorized Official - Last Name:CONLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:970-302-4322
Mailing Address - Street 1:1919 65TH AVE STE COFFICE2
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-7965
Mailing Address - Country:US
Mailing Address - Phone:970-302-4322
Mailing Address - Fax:888-432-0938
Practice Address - Street 1:1919 65TH AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634
Practice Address - Country:US
Practice Address - Phone:970-302-4322
Practice Address - Fax:888-432-0938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10776231Medicaid
COB4290Medicare PIN