Healthcare Provider Details

I. General information

NPI: 1972101202
Provider Name (Legal Business Name): CREEKSIDE PHYSICAL MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S AIRPORT RD UNIT CD
LONGMONT CO
80503-6475
US

IV. Provider business mailing address

5387 MANHATTAN CIR STE 201
BOULDER CO
80303-4283
US

V. Phone/Fax

Practice location:
  • Phone: 303-494-2705
  • Fax:
Mailing address:
  • Phone: 303-494-2705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: LOUISE THOMAS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 303-489-2264