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General NPI Number Information
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NPI Number | 1245336817
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Entity Type | Organization
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Legal Business Name | GINA THE PT LLC
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Dates
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Enumeration Date | 09/14/2006
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Last Update Date | 10/02/2007
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Provider Practice Location Address
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Address Line | 5177 BLACK GORE DR UNIT B1
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City | VAIL
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State | CO
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Zip | 81657-5273
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Country | US
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Telephone | 970-688-1433
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Fax |
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Provider Business Mailing Address
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Address Line | 5177 BLACK GORE DR UNIT B1
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City | VAIL
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State | CO
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Zip | 81657-5273
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | GINA JELACIC
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Credential | MPT
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Telephone | 970-688-1433
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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