Basic Information
| Provider Information | |||||||||
| NPI: | 1497138895 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH BOULDER PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 295 BROKEN FENCE RD | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803029607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036016666 | ||||||||
| FaxNumber: | 3034473390 | ||||||||
| Practice Location | |||||||||
| Address1: | 2750 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034403034 | ||||||||
| FaxNumber: | 3034021665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2015 | ||||||||
| LastUpdateDate: | 03/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | LAYNE | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | JAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3036016666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1413 | CO | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1124076583 | 01 | NPI | OTHER |