Healthcare Provider Details

I. General information

NPI: 1417422643
Provider Name (Legal Business Name): HALEY K VINSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 FLINTRIDGE DR
COLORADO SPRINGS CO
80918-1883
US

IV. Provider business mailing address

510 S PROSPECT ST
COLORADO SPRINGS CO
80903-4552
US

V. Phone/Fax

Practice location:
  • Phone: 719-599-7328
  • Fax:
Mailing address:
  • Phone: 843-360-3354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0014409
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: