Provider Demographics
NPI:1518407675
Name:BOTT, JEFFRY (RMT)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:
Last Name:BOTT
Suffix:
Gender:M
Credentials:RMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 NANTUCKET ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5540
Mailing Address - Country:US
Mailing Address - Phone:970-286-1917
Mailing Address - Fax:
Practice Address - Street 1:1180 MAIN ST
Practice Address - Street 2:ST 7
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-4709
Practice Address - Country:US
Practice Address - Phone:970-686-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0013788225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMT.0013788OtherSTATE