Healthcare Provider Details

I. General information

NPI: 1174879977
Provider Name (Legal Business Name): DAVID A MAIN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7622 MCLAUGHLIN RD
PEYTON CO
80831-4710
US

IV. Provider business mailing address

7622 MCLAUGHLIN RD
PEYTON CO
80831-4710
US

V. Phone/Fax

Practice location:
  • Phone: 719-494-3133
  • Fax: 719-495-8685
Mailing address:
  • Phone: 719-494-3133
  • Fax: 719-495-8685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0011848
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: