Provider Demographics
NPI:1063403855
Name:SERC OF WOODLAND PARK LLC
Entity type:Organization
Organization Name:SERC OF WOODLAND PARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:THESSING
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:719-687-3767
Mailing Address - Street 1:406 E GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-3127
Mailing Address - Country:US
Mailing Address - Phone:719-687-3767
Mailing Address - Fax:719-687-2525
Practice Address - Street 1:406 E GRACE AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-3127
Practice Address - Country:US
Practice Address - Phone:719-687-3767
Practice Address - Fax:719-687-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO801749Medicare ID - Type Unspecified