Provider Demographics
NPI:1669449641
Name:GRAHAM, JOHN CHARLES (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:GRAHAM
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 1:5172 S LAREDO CT
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-4146
Mailing Address - Country:US
Mailing Address - Phone:303-690-9548
Mailing Address - Fax:
Practice Address - Street 1:11021 S PARKER RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-7441
Practice Address - Country:US
Practice Address - Phone:303-841-7737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8522225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC811473Medicare PIN