=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003186446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN RYAN WILLIS LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2012
-----------------------------------------------------
Last Update Date | 01/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12409 ALBION ST
-----------------------------------------------------
City | THORNTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80241-2932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-525-0573
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12409 ALBION ST
-----------------------------------------------------
City | THORNTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80241-2932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-525-0573
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Y00000X
-----------------------------------------------------
Taxonomy Name | Clinical Exercise Physiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 2910
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------