MEDICARE: JONATHAN DAVID GRACE PT

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.0010390	CO

General Provider Information

NPI Number	:	1679067813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN DAVID GRACE PT

Provider Business Mailing Address
First Line	:	9208 GRAND CORDERA PKWY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924-7022
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9208 GRAND CORDERA PKWY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924-7022
Country	:	US
Telephone Number	:	719-522-2000
Fax Number	:

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

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	08/12/2021

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