Provider Demographics
NPI:1891342168
Name:PRIDEMORE, SARAH MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:MARIE
Last Name:PRIDEMORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 PHAY AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 PHAY AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2303
Practice Address - Country:US
Practice Address - Phone:719-275-8656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0014520208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation