Basic Information
| Provider Information | |||||||||
| NPI: | 1740649102 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FEDER | ||||||||
| FirstName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2716 CANOSSA DR | ||||||||
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| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800203811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888734221 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2716 CANOSSA DR | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800203811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888734221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2016 | ||||||||
| LastUpdateDate: | 02/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9382 | MT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.