Provider Demographics
NPI:1497251136
Name:BUENA VISTA PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:BUENA VISTA PHYSICAL THERAPY, LLC
Other - Org Name:BUENA VISTA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:719-297-9009
Mailing Address - Street 1:PO BOX 5005
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81211-5005
Mailing Address - Country:US
Mailing Address - Phone:719-297-9009
Mailing Address - Fax:719-284-7163
Practice Address - Street 1:700 US HWY 24 S
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211
Practice Address - Country:US
Practice Address - Phone:719-297-9009
Practice Address - Fax:719-284-7163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL00119132251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty