MEDICARE: PREMIER PHYSICAL THERAPY, LLC

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	0012749	CO

General Provider Information

NPI Number	:	1407249774
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	12421 W 84TH CIR
Second Line	:
City	:	ARVADA
State	:	CO
Zip	:	80005-5150
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 HIGHLAND PL
Second Line	:
City	:	WESTMINSTER
State	:	CO
Zip	:	80031-3359
Country	:	US
Telephone Number	:	318-715-7994
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KENNETH EVANS MCKENZIE
Credential	:	DPT
Telephone Number	:	318-715-7994

Provider Enumeration Date	:	03/11/2015
Last Update Date	:	11/08/2021

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