Provider Demographics
NPI:1770107179
Name:PENTICUFF, DERRICK CHRISTOPHER
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:CHRISTOPHER
Last Name:PENTICUFF
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 1:4115 CLUB MANOR DR.
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008
Mailing Address - Country:US
Mailing Address - Phone:417-709-5228
Mailing Address - Fax:
Practice Address - Street 1:4115 CLUB MANOR DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008
Practice Address - Country:US
Practice Address - Phone:968-568-9790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist