=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063461440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAYNE PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 07/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2801 YOUNGFIELD ST STE 390
-----------------------------------------------------
City | GOLDEN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80401-2265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-458-6555
-----------------------------------------------------
Fax | 303-274-8063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 295 BROKEN FENCE RD
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80302-9607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-458-6555
-----------------------------------------------------
Fax | 303-274-8063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO OWNER, MANAGING MEMBER
-----------------------------------------------------
Name | MS. DEBRA JAN LAYNE
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 303-601-6666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------