MEDICARE: MR. GARY OPINCARNE PTA

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	225200000X	Physical Therapy Assistant	7999879-2402	UT

General Provider Information

NPI Number	:	1801184866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY OPINCARNE PTA

Provider Business Mailing Address
First Line	:	1530 ZAIGER DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-2247
Country	:	US
Telephone Number	:	719-596-3519
Fax Number	:

Provider Business Practice Location Address
First Line	:	1530 ZAIGER DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-2247
Country	:	US
Telephone Number	:	719-596-3519
Fax Number	:

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

Provider Enumeration Date	:	07/12/2011
Last Update Date	:	07/12/2011

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