Basic Information
| Provider Information | |||||||||
| NPI: | 1295198067 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN COLORADO HEALTH & REHAB | ||||||||
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| OtherOrganizationName: | MOMENTUM PHYSICAL THERAPY OF PUEBLO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5718 | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599035718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067560134 | ||||||||
| FaxNumber: | 4063092579 | ||||||||
| Practice Location | |||||||||
| Address1: | 1275 W PUEBLO BLVD | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195420589 | ||||||||
| FaxNumber: | 7195420119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2016 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | STIMAC | ||||||||
| AuthorizedOfficialFirstName: | BLAINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4067561128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.