Provider Demographics
NPI:1013671429
Name:FOOTHILLS ORTHOPEDIC & SPORT THERAPY, PC
Entity Type:Organization
Organization Name:FOOTHILLS ORTHOPEDIC & SPORT THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:970-667-7755
Mailing Address - Street 1:2964 GINNALA DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-2701
Mailing Address - Country:US
Mailing Address - Phone:970-667-7755
Mailing Address - Fax:
Practice Address - Street 1:3938 JFK PKWY UNIT 11E
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3087
Practice Address - Country:US
Practice Address - Phone:970-207-1500
Practice Address - Fax:970-207-0075
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOTHILLS ORTHOPEDIC & SPORT THERAPY P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-22
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02103354Medicaid