Provider Demographics
NPI: | 1619531852 |
---|---|
Name: | FUNCTIONAL PERFORMANCE MEDICAL SUPPLY, LLC |
Entity Type: | Organization |
Organization Name: | FUNCTIONAL PERFORMANCE MEDICAL SUPPLY, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LAUREN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | OSTRY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DPT |
Authorized Official - Phone: | 970-215-0565 |
Mailing Address - Street 1: | 18293 E EUCLID PL |
Mailing Address - Street 2: | |
Mailing Address - City: | AURORA |
Mailing Address - State: | CO |
Mailing Address - Zip Code: | 80016-1143 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 970-215-0565 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 6169 S BALSAM WAY STE 110 |
Practice Address - Street 2: | |
Practice Address - City: | LITTLETON |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80123-3000 |
Practice Address - Country: | US |
Practice Address - Phone: | 303-948-1868 |
Practice Address - Fax: | 303-948-1741 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | FUNCTIONAL PERFORMANCE PHYSICAL THERAPY CENTER, PLLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2019-04-23 |
Last Update Date: | 2019-04-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |