Provider Demographics
NPI:1497138895
Name:NORTH BOULDER PHYSICAL THERAPY
Entity Type:Organization
Organization Name:NORTH BOULDER PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:JAN
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:303-601-6666
Mailing Address - Street 1:295 BROKEN FENCE RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-9607
Mailing Address - Country:US
Mailing Address - Phone:303-601-6666
Mailing Address - Fax:303-447-3390
Practice Address - Street 1:2750 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3573
Practice Address - Country:US
Practice Address - Phone:303-440-3034
Practice Address - Fax:303-402-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124076583OtherNPI
1124076583OtherNPI