Basic Information
| Provider Information | |||||||||
| NPI: | 1518583616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | TYLOR | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4284 TRAIL BOSS DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | CASTLE ROCK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801047521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036638086 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14400 E JEWELL AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800125689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032835314 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2020 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 17001 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.