Healthcare Provider Details

I. General information

NPI: 1598034308
Provider Name (Legal Business Name): CAROL BENJAMIN, PT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6640 GUNPARK DR SUITE 102
BOULDER CO
80301-7000
US

IV. Provider business mailing address

2119 WESTLAKE DR
LONGMONT CO
80503-8102
US

V. Phone/Fax

Practice location:
  • Phone: 303-938-3770
  • Fax: 720-542-8932
Mailing address:
  • Phone: 303-684-9456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number3878
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. CAROL BENJAMIN
Title or Position: OWNER
Credential: P.T.
Phone: 303-938-3770