Provider Demographics
NPI:1720447964
Name:VILLAGE PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:VILLAGE PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:719-577-4104
Mailing Address - Street 1:545 E PIKES PEAK AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3637
Mailing Address - Country:US
Mailing Address - Phone:719-577-4104
Mailing Address - Fax:719-575-0872
Practice Address - Street 1:801 S PERRY ST
Practice Address - Street 2:SUITE105
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1924
Practice Address - Country:US
Practice Address - Phone:719-577-4104
Practice Address - Fax:719-575-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1497261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA104100Medicare UPIN