Healthcare Provider Details

I. General information

NPI: 1477668838
Provider Name (Legal Business Name): TREVOR LAWRENCE PACE MS DPT PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 30TH STREET SUITE 215
BOULDER CO
80301-1026
US

IV. Provider business mailing address

1800 30TH STREET SUITE 215
BOULDER CO
80301-1026
US

V. Phone/Fax

Practice location:
  • Phone: 303-546-9201
  • Fax: 303-545-5080
Mailing address:
  • Phone: 303-546-9201
  • Fax: 303-545-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6216
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: