Healthcare Provider Details

I. General information

NPI: 1679408801
Provider Name (Legal Business Name): WILD PHYSICAL THERAPY AND PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SUPERIOR DR UNIT B
SUPERIOR CO
80027-8649
US

IV. Provider business mailing address

18967 W 57TH DR
GOLDEN CO
80403-3008
US

V. Phone/Fax

Practice location:
  • Phone: 818-515-0434
  • Fax:
Mailing address:
  • Phone: 818-515-0434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: NICOLE WILDERMUTH
Title or Position: FOUNDER
Credential: DPT,CSCS
Phone: 818-515-0434