Provider Demographics
NPI:1578675120
Name:ALTA PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:ALTA PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-444-8707
Mailing Address - Street 1:2955 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2356
Mailing Address - Country:US
Mailing Address - Phone:303-444-8707
Mailing Address - Fax:303-444-8109
Practice Address - Street 1:2955 BASELINE RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2356
Practice Address - Country:US
Practice Address - Phone:303-444-8707
Practice Address - Fax:303-444-8109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QP2000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========OtherTAX ID
COC25403Medicare ID - Type Unspecified