Healthcare Provider Details

I. General information

NPI: 1497138895
Provider Name (Legal Business Name): NORTH BOULDER PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 BROADWAY ST
BOULDER CO
80304-3573
US

IV. Provider business mailing address

295 BROKEN FENCE RD
BOULDER CO
80302-9607
US

V. Phone/Fax

Practice location:
  • Phone: 303-440-3034
  • Fax: 303-402-1665
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

VII. Legacy identifiers

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

# 1
Identifier1124076583
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI

VIII. Authorized Official

Name: MRS. DEBRA JAN LAYNE
Title or Position: OWNER
Credential: PT
Phone: 303-601-6666