Healthcare Provider Details

I. General information

NPI: 1134450539
Provider Name (Legal Business Name): FORT COLLINS MEDI-SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 01/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 BOARDWALK DR SUITE 100
FORT COLLINS CO
80525-5931
US

IV. Provider business mailing address

4103 BOARDWALK DR SUITE 100
FORT COLLINS CO
80525-5931
US

V. Phone/Fax

Practice location:
  • Phone: 970-204-0400
  • Fax: 970-377-1082
Mailing address:
  • Phone: 970-204-0400
  • Fax: 970-377-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN J ANDERSON
Title or Position: CEO
Credential: OD
Phone: 970-204-0400