Provider Demographics
NPI:1720646722
Name:BOETTCHER, BRETT D
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:D
Last Name:BOETTCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3562 VAN TEYLINGEN DR APT D
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-4837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 6TH ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:CO
Practice Address - Zip Code:80821-2002
Practice Address - Country:US
Practice Address - Phone:719-743-2421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0016399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist