MEDICARE: BREANA LYNN KOFFLER PHYSICAL THERAPIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	7869	CO
2	225400000X	Rehabilitation Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7869	OTHER	CO	PT LISCENSE NUMBER

General Provider Information

NPI Number	:	1043428873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANA LYNN KOFFLER PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	10650 YATES DR
Second Line	:
City	:	WESTMINSTER
State	:	CO
Zip	:	80031-1984
Country	:	US
Telephone Number	:	303-912-4959
Fax Number	:

Provider Business Practice Location Address
First Line	:	413 SUMMIT BLVD
Second Line	:	SUITE 102
City	:	BROOMFIELD
State	:	CO
Zip	:	80021-8294
Country	:	US
Telephone Number	:	303-499-6565
Fax Number	:	303-499-8585

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	12/22/2010

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