Healthcare Provider Details

I. General information

NPI: 1376789552
Provider Name (Legal Business Name): PHYSIOM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 OAKRIDGE DR 130
FORT COLLINS CO
80525-5564
US

IV. Provider business mailing address

PHYSIOM LLC DEPT 2089
DENVER CO
80291-0001
US

V. Phone/Fax

Practice location:
  • Phone: 970-377-9555
  • Fax: 970-377-9559
Mailing address:
  • Phone: 303-922-4636
  • Fax: 303-922-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number31928
License Number StateCO

VIII. Authorized Official

Name: MRS. SHANDEL SCHRODER
Title or Position: BILLING AGENT
Credential:
Phone: 303-922-4636