1306179122 NPI number — MULLIKIN PHYSICAL THERAPY

Table of content: (NPI 1306179122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306179122 NPI number — MULLIKIN PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MULLIKIN PHYSICAL THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306179122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 RAILROAD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCOS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81328-9059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-533-7649
Provider Business Mailing Address Fax Number:
970-533-9089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 RAILROAD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCOS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81328-9059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-533-7649
Provider Business Practice Location Address Fax Number:
970-533-9089
Provider Enumeration Date:
09/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MULLIKIN
Authorized Official First Name:
ANNETTE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PT
Authorized Official Telephone Number:
970-533-7649

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  1930 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 55571034 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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