Provider Demographics
NPI:1952866154
Name:KOPLOW, GREGORY (LMT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:KOPLOW
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 1:619 W BROOKSIDE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-2061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1755 S 8TH ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-7913
Practice Address - Country:US
Practice Address - Phone:719-471-3058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0021601225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist