MEDICARE: FUNCTIONAL PERFORMANCE MEDICAL SUPPLY, 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1619531852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONAL PERFORMANCE MEDICAL SUPPLY, LLC

Provider Business Mailing Address
First Line	:	18293 E EUCLID PL
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80016-1143
Country	:	US
Telephone Number	:	970-215-0565
Fax Number	:

Provider Business Practice Location Address
First Line	:	6169 S BALSAM WAY STE 110
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80123-3000
Country	:	US
Telephone Number	:	303-948-1868
Fax Number	:	303-948-1741

Authorized Official
Title or Position	:	OWNER
Name	:	LAUREN OSTRY
Credential	:	DPT
Telephone Number	:	970-215-0565

Provider Enumeration Date	:	04/23/2019
Last Update Date	:	04/23/2019

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