Provider Demographics
NPI:1639100449
Name:FRONT RANGE THERAPIES CASTLE ROCK
Entity type:Organization
Organization Name:FRONT RANGE THERAPIES CASTLE ROCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNACKI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:303-688-5885
Mailing Address - Street 1:1025 SOUTH PERRY STREET
Mailing Address - Street 2:#101
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104
Mailing Address - Country:US
Mailing Address - Phone:303-688-5885
Mailing Address - Fax:303-688-5903
Practice Address - Street 1:1025 SOUTH PERRY STREET
Practice Address - Street 2:#101
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104
Practice Address - Country:US
Practice Address - Phone:303-688-5885
Practice Address - Fax:303-688-5903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO611202500OtherDEPT OF LABOR
CO001 3059OtherROCKY MOUNTAIN HEALTHPLAN
COFR675117OtherBCBS/ANTHEM
CO========= 01OtherPACIFICARE
CO001 3059OtherROCKY MOUNTAIN HEALTHPLAN
CO611202500OtherDEPT OF LABOR
CO805138Medicare ID - Type Unspecified