Provider Demographics
NPI:1356361802
Name:PROFESSIONAL HEALTH ALLIANCE
Entity type:Organization
Organization Name:PROFESSIONAL HEALTH ALLIANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:303-841-7737
Mailing Address - Street 1:11021 S PARKER RD
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-7441
Mailing Address - Country:US
Mailing Address - Phone:303-841-7737
Mailing Address - Fax:303-840-1777
Practice Address - Street 1:11021 S PARKER RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-7441
Practice Address - Country:US
Practice Address - Phone:303-841-7737
Practice Address - Fax:303-840-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8522261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF5103Medicare ID - Type UnspecifiedPHYSICAL THERAPY CLINIC