MEDICARE: JEFFREY ROBERT FULFORD MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PTL.0011208	CO

General Provider Information

NPI Number	:	1598761298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY ROBERT FULFORD MPT

Provider Business Mailing Address
First Line	:	1760 E KEN PRATT BLVD STE 405
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80504-5311
Country	:	US
Telephone Number	:	720-718-5400
Fax Number	:	720-718-8991

Provider Business Practice Location Address
First Line	:	1760 E KEN PRATT BLVD STE 405
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80504-5311
Country	:	US
Telephone Number	:	720-718-5400
Fax Number	:	720-718-8991

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	06/27/2023

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