Provider Demographics
NPI:1215988936
Name:COLORADO REHABILITATION PHYS
Entity type:Organization
Organization Name:COLORADO REHABILITATION PHYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-776-5673
Mailing Address - Street 1:2222 N NEVADA AVE
Mailing Address - Street 2:STE 5020
Mailing Address - City:COLORADO SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6868
Mailing Address - Country:US
Mailing Address - Phone:719-776-5960
Mailing Address - Fax:719-776-5045
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:STE 5020
Practice Address - City:COLORADO SPGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6868
Practice Address - Country:US
Practice Address - Phone:719-776-5960
Practice Address - Fax:719-776-5045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71151753Medicaid
CO71151753Medicaid