=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043801681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIA ANNE RENKEN PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2021
-----------------------------------------------------
Last Update Date | 01/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11600 W 2ND PL
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80228-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-231-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1583 GROVE ST UNIT 2
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80204-2354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-231-2957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA.0014444
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------