Provider Demographics
NPI:1619601978
Name:REFINED FORM PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:REFINED FORM PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:719-204-3434
Mailing Address - Street 1:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:CRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:81131-0404
Mailing Address - Country:US
Mailing Address - Phone:719-204-3434
Mailing Address - Fax:833-464-2566
Practice Address - Street 1:3704 CAREFREE WAY
Practice Address - Street 2:
Practice Address - City:CRESTONE
Practice Address - State:CO
Practice Address - Zip Code:81131-0404
Practice Address - Country:US
Practice Address - Phone:360-713-7938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty