Basic Information
| Provider Information | |||||||||
| NPI: | 1841890530 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FALCON PHYSICAL THERAPY AND FITNESS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FYZICAL THERAPY AND BALANCE CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7622 MCLAUGHLIN RD | ||||||||
| Address2: | |||||||||
| City: | PEYTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808314710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194953133 | ||||||||
| FaxNumber: | 7194958685 | ||||||||
| Practice Location | |||||||||
| Address1: | 279 S PURCELL BLVD STE 116 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO WEST | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810075083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195472481 | ||||||||
| FaxNumber: | 7195472487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2020 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7194953133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 9000156925 | 05 | CO | MEDICAID |