Healthcare Provider Details

I. General information

NPI: 1003186446
Provider Name (Legal Business Name): JUSTIN RYAN WILLIS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

12409 ALBION ST
THORNTON CO
80241-2932
US

IV. Provider business mailing address

12409 ALBION ST
THORNTON CO
80241-2932
US

V. Phone/Fax

Practice location:
  • Phone: 303-525-0573
  • Fax:
Mailing address:
  • Phone: 303-525-0573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2910
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: