NPIMap

Organization Active NPI

Peak Form LLC

Doing business as Peak Form Medical Clinic

  • Physical Medicine & Rehabilitation Physician
  • Boulder, CO
National Provider Identifier
1982718003
Registry record updated Jul 31, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Medicine & Rehabilitation PhysicianTaxonomy code 208100000X
Legal business name
PEAK FORM LLC
Doing business as
Peak Form Medical Clinic
Peak Form Physical Therapy
Practice address
695 S Broadway St Ste a
Boulder, CO 80305-5925
Phone
(303) 402-9283
Fax
(303) 494-1251
NPI assigned
Aug 18, 2006
Last updated
Jul 31, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 31, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jeanette HrubesNPI 1851405963
Title
Clinic Director
Phone
(720) 939-1058

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X NU
Occupational Health Nurse Practitioner 363LX0106X NU
Physical Medicine & Rehabilitation Physician 208100000X NU Primary
Physical Therapist 225100000X NU
Physical Therapy Assistant 225200000X NU
Massage Therapist 225700000X NU
Clinical Exercise Physiologist 224Y00000X NU

Addresses

Primary practice location

695 S Broadway St Ste a
Boulder, CO 80305-5925

Mailing address

1093 E Bridge St
Brighton, CO 80601-2252
Phone (303) 655-9005

Other names 2

  • Peak Form Medical Clinic Doing business as
  • Peak Form Physical Therapy Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120831000550 CO Part B Supplier - Physical/Occupational Therapy Group in Private Practice 1052212495 Receives reassigned benefits from 16 practitioners
3 other NPIs on this enrollment
Practice locations: Greeley, CO; Broomfield, CO; Boulder, CO; Brighton, CO

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
06D2135358Peak Form Medical Clinic695 South Broadway, Boulder, CO 80305Certificate of waiverAug 20, 2027

National Provider Directory

National Provider Directory
Tax ID family
Peak Form LLC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

693 S Broadway St
Ste E
Boulder, CO 80305
Phone (303) 442-9283

695 S Broadway St
Ste A
Boulder, CO 80305
Phone (303) 402-9283

1093 E Bridge St
Brighton, CO 80601
Phone (303) 655-9005

Practitioners & affiliated clinicians

Practitioners 24

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 24

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155859200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1596153600000",
    "number": "1982718003",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1093 E BRIDGE ST",
            "city": "BRIGHTON",
            "state": "CO",
            "postal_code": "806012252",
            "telephone_number": "303-655-9005",
            "fax_number": "303-655-0063"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "695 S BROADWAY ST STE A",
            "city": "BOULDER",
            "state": "CO",
            "postal_code": "803055925",
            "telephone_number": "303-402-9283",
            "fax_number": "303-494-1251"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEAK FORM LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-18",
        "last_updated": "2020-07-31",
        "certification_date": "2020-07-31",
        "status": "A",
        "authorized_official_last_name": "HRUBES",
        "authorized_official_first_name": "JEANETTE",
        "authorized_official_title_or_position": "CLINIC DIRECTOR",
        "authorized_official_telephone_number": "720-939-1058"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LX0106X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Occupational Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208100000X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "225700000X",
            "taxonomy_group": "",
            "desc": "Massage Therapist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "224Y00000X",
            "taxonomy_group": "",
            "desc": "Clinical Exercise Physiologist",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Peak Form Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Peak Form Physical Therapy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Boulder, CO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 31, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.