Provider Demographics
NPI:1790821403
Name:HOLTBY & BONACK PTR
Entity Type:Organization
Organization Name:HOLTBY & BONACK PTR
Other - Org Name:SPINEWORKS PHYSIOTHERAPY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BONACK
Authorized Official - Suffix:
Authorized Official - Credentials:PT DO MPC
Authorized Official - Phone:719-599-9282
Mailing Address - Street 1:1825 AUSTIN BLUFFS PKWY #100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918
Mailing Address - Country:US
Mailing Address - Phone:719-599-9282
Mailing Address - Fax:719-599-9283
Practice Address - Street 1:1825 AUSTIN BLUFFS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-7861
Practice Address - Country:US
Practice Address - Phone:719-599-9282
Practice Address - Fax:719-599-9283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC469158Medicare PIN