Basic Information
| Provider Information | |||||||||
| NPI: | 1760017388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINCAID | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 E PROSPECT RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704197139 | ||||||||
| FaxNumber: | 9704931794 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 E PROSPECT RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704197139 | ||||||||
| FaxNumber: | 9704931794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2020 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 0016848 | CO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PTL.0016848 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PTL.0016848 | 01 | CO | PHYSICAL THERAPY LICENSE | OTHER |