Provider Demographics
NPI:1962632620
Name:MANUAL EDGE PHYSIOTHERAPY LLC
Entity Type:Organization
Organization Name:MANUAL EDGE PHYSIOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BONACK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:719-694-8342
Mailing Address - Street 1:6189 LEHMAN DR STE 202
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5409
Mailing Address - Country:US
Mailing Address - Phone:719-694-8342
Mailing Address - Fax:719-694-8347
Practice Address - Street 1:6189 LEHMAN DR STE 202
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5409
Practice Address - Country:US
Practice Address - Phone:719-694-8342
Practice Address - Fax:719-694-8347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23732251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4740Medicare PIN