Provider Demographics
NPI:1265258024
Name:MANUAL EDGE PHYSICAL THERAPY SPECIALISTS LLC
Entity type:Organization
Organization Name:MANUAL EDGE PHYSICAL THERAPY SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/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:
Authorized Official - Phone:719-694-8342
Mailing Address - Street 1:1840 WOODMOOR DR STE 106
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-9098
Mailing Address - Country:US
Mailing Address - Phone:719-694-9747
Mailing Address - Fax:719-694-9832
Practice Address - Street 1:1840 WOODMOOR DR STE 106
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-9098
Practice Address - Country:US
Practice Address - Phone:719-694-9747
Practice Address - Fax:719-694-9832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
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
COPENDINGMedicaid