Healthcare Provider Details

I. General information

NPI: 1831863117
Provider Name (Legal Business Name): PEAK FORM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 E 1ST AVE
BROOMFIELD CO
80020-3792
US

IV. Provider business mailing address

1093 E BRIDGE ST
BRIGHTON CO
80601-2252
US

V. Phone/Fax

Practice location:
  • Phone: 303-655-9005
  • Fax:
Mailing address:
  • Phone: 303-655-9005
  • Fax: 303-655-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. PATRICIA OCONNOR
Title or Position: FRONT DESK COORDINATOR
Credential:
Phone: 303-655-9005