Healthcare Provider Details

I. General information

NPI: 1134270085
Provider Name (Legal Business Name): RED LADY SPINE & SPORTS PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 BELLEVIEW AVE. SUITE 105
CRESTED BUTTE CO
81224-1117
US

IV. Provider business mailing address

PO BOX 1117
CRESTED BUTTE CO
81224-1117
US

V. Phone/Fax

Practice location:
  • Phone: 970-349-2772
  • Fax: 970-349-0459
Mailing address:
  • Phone: 970-349-2772
  • Fax: 970-349-0459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3665
License Number StateCO

VIII. Authorized Official

Name: MS. SHELLEY R THOMAS
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 97803492772