| Organization Name: | EXECUTIVE PHYSICAL THERAPY, INC. |
| NPI Number: | 1588834121 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | CAROLINE CORNING CREAGER (OWNER) |
| Mailing Address: | 247 Mountain Avenue Berthoud |
| State: | CO US |
| Postal Code: | 80513 |
| Phone Number: | 9705322533 |
| Fax Number: | 9705325450 |
| NPI Enumeration Date: | 03/11/2008 |
| NPI Last Update Date: | 03/11/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2000X |
| License Number: | 3219 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CO |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Physical Therapy |
| Taxonomy Definition: | |