Basic Information
| Provider Information | |||||||||
| NPI: | 1457444085 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORM AND FITNESS PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13606 XAVIER LANE | ||||||||
| Address2: | STE C | ||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034049494 | ||||||||
| FaxNumber: | 3034042252 | ||||||||
| Practice Location | |||||||||
| Address1: | 13606 XAVIER LANE | ||||||||
| Address2: | STE C | ||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034049494 | ||||||||
| FaxNumber: | 3034042252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | FORMAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | NEIL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER, PT | ||||||||
| AuthorizedOfficialTelephone: | 3034049494 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 6265 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.