Basic Information
| Provider Information | |||||||||
| NPI: | 1225430606 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN BAVEL | ||||||||
| FirstName: | CONNOR | ||||||||
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| Credential: | M.SC.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13606 XAVIER LN | ||||||||
| Address2: | UNIT C | ||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800233604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034049494 | ||||||||
| FaxNumber: | 3034042252 | ||||||||
| Practice Location | |||||||||
| Address1: | 12297 PENNSYLVANIA ST | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802413165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032529400 | ||||||||
| FaxNumber: | 3032559555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2014 | ||||||||
| LastUpdateDate: | 04/22/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTL.0012807 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 9000144743 | 05 | CO | MEDICAID |