Healthcare Provider Details

I. General information

NPI: 1417735473
Provider Name (Legal Business Name): THORACIC PARK HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 03/17/2024
Certification Date: 03/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5641 IRIS PKWY UNIT D
FREDERICK CO
80504-6925
US

IV. Provider business mailing address

11169 E I25 FRONTAGE RD STE C
FIRESTONE CO
80504-5211
US

V. Phone/Fax

Practice location:
  • Phone: 720-600-0370
  • Fax:
Mailing address:
  • Phone: 720-600-0370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER EDMUNDSON
Title or Position: MEMBER
Credential: PT, DPT
Phone: 617-275-6818