Healthcare Provider Details

I. General information

NPI: 1124076583
Provider Name (Legal Business Name): NORTH BOULDER PHYSICAL THERAPY SPORTS REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 CENTER GREEN DR 110
BOULDER CO
80301-2364
US

IV. Provider business mailing address

295 BROKEN FENCE RD NORTH BOULDER PHYSICAL THERAPY/DEBRA LAYNE
BOULDER CO
80302-9607
US

V. Phone/Fax

Practice location:
  • Phone: 303-413-9903
  • Fax: 303-413-9907
Mailing address:
  • Phone: 303-601-6666
  • Fax: 303-447-3390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1413
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberNOT APPLICABLE
License Number StateCO

VIII. Authorized Official

Name: MS. DEBRA JAN LAYNE
Title or Position: OWNER, MANAGING MEMBER
Credential: PT
Phone: 303-601-6666