Healthcare Provider Details

I. General information

NPI: 1669354817
Provider Name (Legal Business Name): MUSCLE RESTORATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4532 MCMURRY AVE UNIT 204
FORT COLLINS CO
80525-8022
US

IV. Provider business mailing address

4532 MCMURRY AVE UNIT 204
FORT COLLINS CO
80525-8022
US

V. Phone/Fax

Practice location:
  • Phone: 402-363-1864
  • Fax:
Mailing address:
  • Phone: 402-363-1864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: JONAH OTTE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 970-449-9757