Basic Information
| Provider Information | |||||||||
| NPI: | 1326791294 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLORADO ATHLETIC CONDITIONING CLINIC LOWRY PROFESSIONAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 392977 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152515238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243434060 | ||||||||
| FaxNumber: | 7243434060 | ||||||||
| Practice Location | |||||||||
| Address1: | 10439 CHAMBERS RD | ||||||||
| Address2: | |||||||||
| City: | COMMERCE CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800228929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7206258198 | ||||||||
| FaxNumber: | 7207924514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2022 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | REDFERN CATALDO | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4125672400 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLORADO ATHLETIC CONDITIONING CLINIC LOWRY PROFESSIONAL LLC | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.