Healthcare Provider Details

I. General information

NPI: 1053640599
Provider Name (Legal Business Name): JEANNE A. HERGENROTHER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2009
Last Update Date: 12/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 S MAIN ST
DELTA CO
81416-2407
US

IV. Provider business mailing address

PO BOX 1352
PAGOSA SPRINGS CO
81147-1352
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-9773
  • Fax:
Mailing address:
  • Phone: 970-731-7474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5647
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: