Provider Demographics
NPI:1760057970
Name:VINEYARD, MACKENZIE BLAKE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:BLAKE
Last Name:VINEYARD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 S POTOMAC ST STE 400
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4540
Mailing Address - Country:US
Mailing Address - Phone:303-671-2134
Mailing Address - Fax:303-671-2142
Practice Address - Street 1:1411 S POTOMAC ST STE 400
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4540
Practice Address - Country:US
Practice Address - Phone:303-671-2134
Practice Address - Fax:303-671-2142
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0017060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist