MEDICARE: MY HEROES, 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
2	225X00000X	Occupational Therapist
3	261QP2000X	Physical Therapy Clinic/Center	PT007063	GA
4	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	52704274	OTHER	GA	BCBS OF GA PROVIDER ID

General Provider Information

NPI Number	:	1811021157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY HEROES, LLC

Provider Business Mailing Address
First Line	:	316 S WASHINGTON AVE
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-2559
Country	:	US
Telephone Number	:	678-984-7774
Fax Number	:	888-551-6210

Provider Business Practice Location Address
First Line	:	725 S OVERLAND TRAIL
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-1669
Country	:	US
Telephone Number	:	678-984-7774
Fax Number	:	888-551-6210

Authorized Official
Title or Position	:	OWNER
Name	:	MR. GEORGE BRENT APPLEGATE
Credential	:	MPT, HPCS
Telephone Number	:	678-984-7774

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	05/13/2024

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Directions to “MY HEROES, LLC ” Practice Location

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