MEDICARE: KAREN CHURCH PHYSICAL THERAPY P C

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	3618	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CH15793	OTHER		BLUE CROSS

General Provider Information

NPI Number	:	1689651937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAREN CHURCH PHYSICAL THERAPY P C

Provider Business Mailing Address
First Line	:	PO BOX 0541
Second Line	:
City	:	GLENWOOD SPGS
State	:	CO
Zip	:	81602-0541
Country	:	US
Telephone Number	:	970-945-1443
Fax Number	:	970-947-9410

Provider Business Practice Location Address
First Line	:	710 COOPER AVE STE 100
Second Line	:
City	:	GLENWOOD SPGS
State	:	CO
Zip	:	81601-3446
Country	:	US
Telephone Number	:	970-945-6971
Fax Number	:	970-928-7975

Authorized Official
Title or Position	:	PRESIDENT PHYSICAL THERAPIST
Name	:	KAREN CHURCH
Credential	:	RPT
Telephone Number	:	970-945-6971

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	03/19/2009

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