Basic Information
| Provider Information | |||||||||
| NPI: | 1982842035 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORM AND FITNESS PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13606 XAVIER LN STE C | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800233604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3003404949 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16151 LOWELL BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800238100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034049494 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2009 | ||||||||
| LastUpdateDate: | 01/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | FORMAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3034049494 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.