Provider Demographics
NPI:1134270085
Name:RED LADY SPINE & SPORTS PHYSICAL THERAPY
Entity type:Organization
Organization Name:RED LADY SPINE & SPORTS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:9780-349-2772
Mailing Address - Street 1:PO BOX 1117
Mailing Address - Street 2:
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224-1117
Mailing Address - Country:US
Mailing Address - Phone:970-349-2772
Mailing Address - Fax:970-349-0459
Practice Address - Street 1:427 BELLEVIEW AVE.
Practice Address - Street 2:SUITE 105
Practice Address - City:CRESTED BUTTE
Practice Address - State:CO
Practice Address - Zip Code:81224-1117
Practice Address - Country:US
Practice Address - Phone:970-349-2772
Practice Address - Fax:970-349-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3665225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC450418Medicare ID - Type Unspecified