=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770060592
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRAD WHITWORTH LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2018
-----------------------------------------------------
Last Update Date | 07/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2570 S COLORADO BLVD
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80222-5909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-609-7033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4400 S QUEBEC ST APT C208
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80237-2667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-619-3016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT.0021547
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------