=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811568553
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTSIDE PT,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2021
-----------------------------------------------------
Last Update Date | 07/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 W COLORADO AVE # C-305
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80904-3882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-237-8241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 540 MESA VISTA CT
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80904-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-237-8241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MELINDA COUCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-237-8241
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------