Healthcare Provider Details

I. General information

NPI: 1164945051
Provider Name (Legal Business Name): ANGELO PETRIELLO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 W PUEBLO BLVD
PUEBLO CO
81004-3866
US

IV. Provider business mailing address

PO BOX 5718
KALISPELL MT
59903-5718
US

V. Phone/Fax

Practice location:
  • Phone: 719-542-0589
  • Fax: 719-542-0119
Mailing address:
  • Phone: 406-756-0134
  • Fax: 406-309-2579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number293255
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL0016672
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: