1588166532 NPI number — MATT DESTEFANO DPT

Table of content: MATT DESTEFANO DPT (NPI 1588166532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588166532 NPI number — MATT DESTEFANO DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESTEFANO
Provider First Name:
MATT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

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:
1588166532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2512
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TELLURIDE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81435-2512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 E COLORADO AVE
Provider Second Line Business Practice Location Address:
BALANCED THERAPY, LLC
Provider Business Practice Location Address City Name:
TELLURIDE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-728-8948
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2018

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:  PTL.0015370 , 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)