Healthcare Provider Details

I. General information

NPI: 1538238399
Provider Name (Legal Business Name): CORTEZ PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 RAILROAD AVE
MANCOS CO
81328-9059
US

IV. Provider business mailing address

121 RAILROAD AVE
MANCOS CO
81328-9059
US

V. Phone/Fax

Practice location:
  • Phone: 970-533-7649
  • Fax: 970-533-9089
Mailing address:
  • Phone: 970-533-7649
  • Fax: 970-533-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number1930 PHYSICL THERAP
License Number StateCO

VIII. Authorized Official

Name: MRS. ANNETTE M. MULLIKIN
Title or Position: OWNER
Credential: P.T.
Phone: 970-533-7649