Provider Demographics
NPI:1922540558
Name:COLORADO OCCUPATIONAL AND LYMPHEDEMA THERAPY LLC
Entity Type:Organization
Organization Name:COLORADO OCCUPATIONAL AND LYMPHEDEMA THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J E
Authorized Official - Last Name:FYFFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-508-3996
Mailing Address - Street 1:2624 ESPINOZA ST
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-3913
Mailing Address - Country:US
Mailing Address - Phone:419-508-3996
Mailing Address - Fax:
Practice Address - Street 1:2624 ESPINOZA ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-3913
Practice Address - Country:US
Practice Address - Phone:419-508-3996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0002493261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation