Healthcare Provider Details

I. General information

NPI: 1568519320
Provider Name (Legal Business Name): THE TINY TIM CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 KORTE WAY
LONGMONT CO
80501-6366
US

IV. Provider business mailing address

611 KORTE WAY
LONGMONT CO
80501-6366
US

V. Phone/Fax

Practice location:
  • Phone: 303-776-7417
  • Fax: 303-776-7471
Mailing address:
  • Phone: 303-776-7417
  • Fax: 303-776-7471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MATT ELDRED
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 303-776-7417