Provider Demographics
NPI:1740346501
Name:WELLNESS PROFESSIONALS
Entity type:Organization
Organization Name:WELLNESS PROFESSIONALS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-702-1991
Mailing Address - Street 1:833 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3926
Mailing Address - Country:US
Mailing Address - Phone:303-702-1991
Mailing Address - Fax:
Practice Address - Street 1:16 MOUNTAIN VIEW AVE STE 102
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3420
Practice Address - Country:US
Practice Address - Phone:303-702-1991
Practice Address - Fax:303-776-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC800614Medicare ID - Type UnspecifiedPROVIDER NUMBER