Healthcare Provider Details

I. General information

NPI: 1386093102
Provider Name (Legal Business Name): KRYSTAL KOBORDO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1667 SAINT PAUL ST
DENVER CO
80206-1614
US

IV. Provider business mailing address

3701 ARAPAHOE AVE UNIT 317
BOULDER CO
80303-3303
US

V. Phone/Fax

Practice location:
  • Phone: 303-399-2040
  • Fax:
Mailing address:
  • Phone: 484-375-5789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.0013781
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: