Provider Demographics
NPI:1790805000
Name:VILLAGE PHYSICAL THERAPY, P.C.
Entity Type:Organization
Organization Name:VILLAGE PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:719-577-4104
Mailing Address - Street 1:545 E PIKES PEAK AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3637
Mailing Address - Country:US
Mailing Address - Phone:719-577-4104
Mailing Address - Fax:719-575-0872
Practice Address - Street 1:109 LATIGO LN
Practice Address - Street 2:SUITE A
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-8112
Practice Address - Country:US
Practice Address - Phone:719-562-0328
Practice Address - Fax:719-575-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC20353Medicare ID - Type UnspecifiedPROVIDER NUMBER