Healthcare Provider Details

I. General information

NPI: 1487636247
Provider Name (Legal Business Name): OSTEOPATHIC TREATMENT CENTER P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

697 1675 RD
DELTA CO
81416-3462
US

IV. Provider business mailing address

697 1675 RD
DELTA CO
81416-3462
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-9595
  • Fax: 970-240-8823
Mailing address:
  • Phone: 970-874-9595
  • Fax: 970-240-8823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number30332
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number30332
License Number StateCO

VIII. Authorized Official

Name: MICHELLE JENKINS
Title or Position: OFFICE MANAGER
Credential:
Phone: 970-240-8822