Healthcare Provider Details

I. General information

NPI: 1760489512
Provider Name (Legal Business Name): TED NEIL LAYNE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 02/16/2008
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
BOULDER CO
80302-9607
US

V. Phone/Fax

Practice location:
  • Phone: 303-449-3431
  • Fax: 303-447-3390
Mailing address:
  • Phone: 303-449-3431
  • Fax: 303-447-3390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1542
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier1542
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerPHYSICAL THERAPY LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: