Healthcare Provider Details

I. General information

NPI: 1144685801
Provider Name (Legal Business Name): FORT COLLINS FUNCTIONAL MOVEMENT INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E LINCOLN AVE
FORT COLLINS CO
80524
US

IV. Provider business mailing address

234 BISHOP ST
FORT COLLINS CO
80521-1708
US

V. Phone/Fax

Practice location:
  • Phone: 970-818-0060
  • Fax: 970-549-8464
Mailing address:
  • Phone: 970-492-5619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number8810
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MISS LISA E DEBORD
Title or Position: MANAGER
Credential: PT
Phone: 970-492-5619