Basic Information
| Provider Information | |||||||||
| NPI: | 1336451954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASPEN GROVE PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2233 E. MAIN STREET | ||||||||
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| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707650818 | ||||||||
| FaxNumber: | 9704978410 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 S 9TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702404015 | ||||||||
| FaxNumber: | 9702491983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2010 | ||||||||
| LastUpdateDate: | 04/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | PACKARD | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9702404015 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8997 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | DT0690 | 01 | RAILROAD WORKERS MEDICARE | OTHER |