Provider Demographics
NPI:1639155708
Name:INSTITUTE OF PHYSICAL MEDICINE & SPORTS THERAPY INC
Entity Type:Organization
Organization Name:INSTITUTE OF PHYSICAL MEDICINE & SPORTS THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:970-674-8011
Mailing Address - Street 1:1455 MAIN ST
Mailing Address - Street 2:STE 170
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5561
Mailing Address - Country:US
Mailing Address - Phone:970-674-8011
Mailing Address - Fax:970-674-8051
Practice Address - Street 1:1455 MAIN ST STE 170
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5561
Practice Address - Country:US
Practice Address - Phone:970-674-8011
Practice Address - Fax:970-674-8051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C801619Medicare PIN