1043428873 NPI number — BREANA LYNN KOFFLER PHYSICAL THERAPIST

Table of content: BREANA LYNN KOFFLER PHYSICAL THERAPIST (NPI 1043428873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043428873 NPI number — BREANA LYNN KOFFLER PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOFFLER
Provider First Name:
BREANA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

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:
1043428873
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10650 YATES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTMINSTER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80031-1984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-912-4959
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 SUMMIT BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BROOMFIELD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80021-8294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-499-6565
Provider Business Practice Location Address Fax Number:
303-499-8585
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  7869 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7869 . This is a "PT LISCENSE NUMBER" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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