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General NPI Number Information
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NPI Number | 1679408801
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Entity Type | Organization
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Legal Business Name | WILD PHYSICAL THERAPY AND PERFORMANCE
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Dates
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Enumeration Date | 06/17/2026
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Last Update Date | 06/17/2026
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Provider Practice Location Address
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Address Line | 1 SUPERIOR DR UNIT B
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City | SUPERIOR
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State | CO
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Zip | 80027-8649
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Country | US
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Telephone | 818-515-0434
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Fax |
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Provider Business Mailing Address
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Address Line | 18967 W 57TH DR
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City | GOLDEN
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State | CO
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Zip | 80403-3008
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Country | US
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Telephone | 818-515-0434
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Fax |
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Authorized Official
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Title or Position | FOUNDER
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Name | NICOLE WILDERMUTH
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Credential | DPT,CSCS
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Telephone | 818-515-0434
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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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