Provider Demographics
NPI:1679703888
Name:FUNCTIONAL PERFORMANCE PHYSICAL THERAPY CENTER
Entity Type:Organization
Organization Name:FUNCTIONAL PERFORMANCE PHYSICAL THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:303-981-9870
Mailing Address - Street 1:6169 S BALSAM WAY
Mailing Address - Street 2:STE 110
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80123-3062
Mailing Address - Country:US
Mailing Address - Phone:303-948-1868
Mailing Address - Fax:303-948-1741
Practice Address - Street 1:12257 S WADSWORTH BLVD
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80125-8504
Practice Address - Country:US
Practice Address - Phone:303-981-9870
Practice Address - Fax:303-416-4271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9903261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1518193895OtherNPI- ORGANIZATION
COC811839Medicare UPIN