Basic Information
| Provider Information | |||||||||
| NPI: | 1043700594 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLORADO SPORTS PHYSICAL THERAPY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 390 EMPIRE RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800262606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202165128 | ||||||||
| FaxNumber: | 7203166744 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 EMPIRE RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800262606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102790479 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2018 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | SCHNELL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7202165128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT, DPT, SCS | ||||||||
| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | 0015257 | CO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
No ID Information.