MEDICARE: PACKER NEURODIAGNOSTICS, 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

General Provider Information

NPI Number	:	1952294779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACKER NEURODIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	4625 TRAIL BOSS DR STE F
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-2803
Country	:	US
Telephone Number	:	208-243-4832
Fax Number	:

Provider Business Practice Location Address
First Line	:	4625 TRAIL BOSS DR STE F
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-2803
Country	:	US
Telephone Number	:	208-243-4832
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/MANAGER
Name	:	DR. ZAC PACKER
Credential	:	DPT
Telephone Number	:	208-243-4832

Provider Enumeration Date	:	05/30/2025
Last Update Date	:	05/30/2025

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