Provider Demographics
NPI:1972101202
Name:CREEKSIDE PHYSICAL MEDICINE PLLC
Entity Type:Organization
Organization Name:CREEKSIDE PHYSICAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-489-2264
Mailing Address - Street 1:5387 MANHATTAN CIR STE 201
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4283
Mailing Address - Country:US
Mailing Address - Phone:303-494-2705
Mailing Address - Fax:
Practice Address - Street 1:600 S AIRPORT RD UNIT CD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6475
Practice Address - Country:US
Practice Address - Phone:303-494-2705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CREEKSIDE PHYSICAL MEDICINE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty