Healthcare Provider Details

I. General information

NPI: 1366801656
Provider Name (Legal Business Name): PHYSIOMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 INVERNESS CIR E A105
ENGLEWOOD CO
80112-5304
US

IV. Provider business mailing address

88 INVERNESS CIR E A105
ENGLEWOOD CO
80112-5304
US

V. Phone/Fax

Practice location:
  • Phone: 303-925-1050
  • Fax:
Mailing address:
  • Phone: 303-925-1050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TYLER CORBIN FOWLER
Title or Position: MEMBER
Credential: DC
Phone: 303-925-1050