Healthcare Provider Details

I. General information

NPI: 1174642045
Provider Name (Legal Business Name): PHYSICAL THERAPY CONNECTIONS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 GLEN ROYAL DR
PUEBLO CO
81005-2174
US

IV. Provider business mailing address

58 GLEN ROYAL DR
PUEBLO CO
81005-2263
US

V. Phone/Fax

Practice location:
  • Phone: 719-565-6678
  • Fax: 719-561-0577
Mailing address:
  • Phone: 719-565-6678
  • Fax: 719-561-0577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5835
License Number StateCO

VIII. Authorized Official

Name: MR. CHAD A. CLARK
Title or Position: PHYSICAL THERAPIST, OWNER
Credential: MSPT, CSCS
Phone: 719-565-6678