MEDICARE: WESLEY SPICE PTA

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	225200000X	Physical Therapy Assistant	PTA 0012075	CO

General Provider Information

NPI Number	:	1720429772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WESLEY SPICE PTA

Provider Business Mailing Address
First Line	:	6451 E 78TH AVE
Second Line	:
City	:	COMMERCE CITY
State	:	CO
Zip	:	80022-1163
Country	:	US
Telephone Number	:	720-427-5568
Fax Number	:

Provider Business Practice Location Address
First Line	:	8301 E PRENTICE AVE
Second Line	:
City	:	GREENWOOD VILLAGE
State	:	CO
Zip	:	80111-2903
Country	:	US
Telephone Number	:	719-630-7500
Fax Number	:

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

Provider Enumeration Date	:	07/07/2013
Last Update Date	:	07/07/2013

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