Provider Demographics
NPI:1124076583
Name:NORTH BOULDER PHYSICAL THERAPY SPORTS REHABILITATION LLC
Entity type:Organization
Organization Name:NORTH BOULDER PHYSICAL THERAPY SPORTS REHABILITATION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:JAN
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:303-601-6666
Mailing Address - Street 1:295 BROKEN FENCE RD
Mailing Address - Street 2:NORTH BOULDER PHYSICAL THERAPY/DEBRA LAYNE
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-9607
Mailing Address - Country:US
Mailing Address - Phone:303-601-6666
Mailing Address - Fax:303-447-3390
Practice Address - Street 1:3000 CENTER GREEN DR
Practice Address - Street 2:110
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2364
Practice Address - Country:US
Practice Address - Phone:303-413-9903
Practice Address - Fax:303-413-9907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONOT APPLICABLE225XH1200X
CO1413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCR5903Medicare PIN