MEDICARE: VILLAGE PHYSICAL THERAPY, PC

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	261QP2000X	Physical Therapy Clinic/Center	1497	CO

General Provider Information

NPI Number	:	1720447964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGE PHYSICAL THERAPY, PC

Provider Business Mailing Address
First Line	:	545 E PIKES PEAK AVE
Second Line	:	SUITE 320
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-3637
Country	:	US
Telephone Number	:	719-577-4104
Fax Number	:	719-575-0872

Provider Business Practice Location Address
First Line	:	801 S PERRY ST
Second Line	:	SUITE105
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-1924
Country	:	US
Telephone Number	:	719-577-4104
Fax Number	:	719-575-0872

Authorized Official
Title or Position	:	PRESIDENT/PHYSICAL THERAPIST
Name	:	MICHELE CHILDS
Credential	:	PT
Telephone Number	:	719-577-4104

Provider Enumeration Date	:	02/16/2016
Last Update Date	:	02/16/2016

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