Provider Demographics
NPI:1851063358
Name:DEFONSO, ERIC (LMT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:DEFONSO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5470 HYGIENE RD
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-9150
Mailing Address - Country:US
Mailing Address - Phone:970-818-1567
Mailing Address - Fax:
Practice Address - Street 1:5470 HYGIENE RD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-9150
Practice Address - Country:US
Practice Address - Phone:970-818-1567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0018510225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist