=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538378211
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN THORNTON OTR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 HARDING AVE
-----------------------------------------------------
City | CANON CITY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81212-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-371-3615
-----------------------------------------------------
Fax | 719-269-8305
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6153 MIRAMONT ST
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80922-3480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-371-3615
-----------------------------------------------------
Fax | 719-269-8305
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------