Provider Demographics
NPI:1639251986
Name:RETTIG, ROGER C (PT)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:C
Last Name:RETTIG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 NICKEL ST
Mailing Address - Street 2:STE 6
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2097
Mailing Address - Country:US
Mailing Address - Phone:303-460-9123
Mailing Address - Fax:303-469-2324
Practice Address - Street 1:300 NICKEL ST
Practice Address - Street 2:SUITE 6
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2097
Practice Address - Country:US
Practice Address - Phone:303-460-9129
Practice Address - Fax:303-469-2324
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06-6570Medicare ID - Type Unspecified