Provider Demographics
NPI:1023093200
Name:FARNWORTH, DANE M (PT)
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:M
Last Name:FARNWORTH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 612260
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95161-2260
Mailing Address - Country:US
Mailing Address - Phone:877-325-2776
Mailing Address - Fax:408-945-4011
Practice Address - Street 1:3525 SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2208
Practice Address - Country:US
Practice Address - Phone:719-542-4444
Practice Address - Fax:719-543-1990
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPT 6541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist