Provider Demographics
NPI:1588675821
Name:SPORTS REHAB AND PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:SPORTS REHAB AND PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SUCHUL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:303-632-5280
Mailing Address - Street 1:2295 S CHAMBERS RD STE J
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-4547
Mailing Address - Country:US
Mailing Address - Phone:303-632-5280
Mailing Address - Fax:303-632-5271
Practice Address - Street 1:2295 S CHAMBERS RD STE J
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-4547
Practice Address - Country:US
Practice Address - Phone:303-632-5280
Practice Address - Fax:303-632-5271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7958170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14830086Medicaid
COC472528Medicare ID - Type Unspecified