Provider Demographics
NPI:1649609405
Name:PHYSICAL THERAPY AND LIFETIME WELLNESS, LLC
Entity type:Organization
Organization Name:PHYSICAL THERAPY AND LIFETIME WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:WALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS, CSCS
Authorized Official - Phone:303-578-2490
Mailing Address - Street 1:PO BOX 61041
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-1041
Mailing Address - Country:US
Mailing Address - Phone:800-615-7550
Mailing Address - Fax:800-797-7110
Practice Address - Street 1:701 S LOGAN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-4199
Practice Address - Country:US
Practice Address - Phone:800-615-7550
Practice Address - Fax:800-797-7110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10315261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy