Provider Demographics
NPI:1053449744
Name:MADSEN, KENT ALLEN (PT)
Entity type:Individual
Prefix:MR
First Name:KENT
Middle Name:ALLEN
Last Name:MADSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 OAK RD
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-2941
Mailing Address - Country:US
Mailing Address - Phone:719-336-4364
Mailing Address - Fax:719-336-4365
Practice Address - Street 1:6935 U.S. HWY 50
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052
Practice Address - Country:US
Practice Address - Phone:719-336-4364
Practice Address - Fax:719-336-4365
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2412225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC536308Medicare PIN