Provider Demographics
NPI:1790223477
Name:PREMIER PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PREMIER PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-715-7994
Mailing Address - Street 1:5008 W 92ND AVE
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-6302
Mailing Address - Country:US
Mailing Address - Phone:303-412-7035
Mailing Address - Fax:303-412-7993
Practice Address - Street 1:5008 W 92ND AVE
Practice Address - Street 2:SUITE A-3
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-6302
Practice Address - Country:US
Practice Address - Phone:303-412-7035
Practice Address - Fax:303-412-7993
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0012749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty