Provider Demographics
NPI:1396789921
Name:BOTHA, ANDRE (RPT, DIPMDT)
Entity type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:
Last Name:BOTHA
Suffix:
Gender:M
Credentials:RPT, DIPMDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ROCK POINT DR
Mailing Address - Street 2:STE C
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7728
Mailing Address - Country:US
Mailing Address - Phone:970-247-7895
Mailing Address - Fax:970-459-8404
Practice Address - Street 1:1600 FLORIDA RD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-6836
Practice Address - Country:US
Practice Address - Phone:970-385-6969
Practice Address - Fax:970-247-7810
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO375292YSK3OtherMEDICARE PTAN
HI00D021785-3Medicaid
CO92882056Medicaid