Healthcare Provider Details

I. General information

NPI: 1437577657
Provider Name (Legal Business Name): KENT ELY MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 SCARBOROUGH DR SUITE 200
COLORADO SPRINGS CO
80920-7502
US

IV. Provider business mailing address

2815 DOROMUS COURT
COLORADO SPRINGS CO
80920
UM

V. Phone/Fax

Practice location:
  • Phone: 719-630-7500
  • Fax:
Mailing address:
  • Phone: 719-282-7746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0006782
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: