Healthcare Provider Details

I. General information

NPI: 1720429772
Provider Name (Legal Business Name): WESLEY SPICE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2013
Last Update Date: 07/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8301 E PRENTICE AVE
GREENWOOD VILLAGE CO
80111-2903
US

IV. Provider business mailing address

6451 E 78TH AVE
COMMERCE CITY CO
80022-1163
US

V. Phone/Fax

Practice location:
  • Phone: 719-630-7500
  • Fax:
Mailing address:
  • Phone: 720-427-5568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 0012075
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: