Basic Information
| Provider Information | |||||||||
| NPI: | 1164083580 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAINWARING | ||||||||
| FirstName: | GRACE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2430 RESEARCH PKWY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809201093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196231050 | ||||||||
| FaxNumber: | 7196231051 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 MEDICAL CENTER PT STE 180 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809075798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193449497 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2019 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0000151 | 01 | CO | TEMP LICENSE | OTHER |