Provider Demographics
NPI:1477855179
Name:MOVEMENT PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:MOVEMENT PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WACKER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CSCS
Authorized Official - Phone:970-217-8018
Mailing Address - Street 1:PO BOX 1784
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-1784
Mailing Address - Country:US
Mailing Address - Phone:970-926-0767
Mailing Address - Fax:
Practice Address - Street 1:216 MAIN ST UNIT C-104
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-8127
Practice Address - Country:US
Practice Address - Phone:970-926-0767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8600261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy