Healthcare Provider Details

I. General information

NPI: 1790750008
Provider Name (Legal Business Name): PRO-REHAB AND FITNESS CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N COMMERCIAL ST
TRINIDAD CO
81082-2611
US

IV. Provider business mailing address

323 N COMMERCIAL ST
TRINIDAD CO
81082-2611
US

V. Phone/Fax

Practice location:
  • Phone: 719-846-8668
  • Fax: 719-846-8629
Mailing address:
  • Phone: 719-846-8668
  • Fax: 719-846-8629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JULIANNE BUTLER
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 719-846-8668