Provider Demographics
NPI:1790850824
Name:ADVANTAGE PHYSICAL THERAPY & WELLNESS, PC
Entity Type:Organization
Organization Name:ADVANTAGE PHYSICAL THERAPY & WELLNESS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TESTA
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:970-259-7829
Mailing Address - Street 1:3600 MAIN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4031
Mailing Address - Country:US
Mailing Address - Phone:970-259-7829
Mailing Address - Fax:970-259-9411
Practice Address - Street 1:3600 MAIN AVE STE A
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4031
Practice Address - Country:US
Practice Address - Phone:970-259-7829
Practice Address - Fax:970-259-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25-38638-0000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC535178Medicare ID - Type Unspecified