1780651158 NPI number — PHYSICAL THERAPY COMPLETE PLLC

Table of content: (NPI 1780651158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780651158 NPI number — PHYSICAL THERAPY COMPLETE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL THERAPY COMPLETE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1780651158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
375 E VIRGINIA AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85004-1220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-264-5323
Provider Business Mailing Address Fax Number:
602-264-5302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 E VIRGINIA AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85004-1220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-264-5323
Provider Business Practice Location Address Fax Number:
602-264-5302
Provider Enumeration Date:
03/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLEASON
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
OWNER/MEMBER
Authorized Official Telephone Number:
602-264-5323

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2Z1876 . This is a "HEALTHNET PROVIDER ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 8145185 . This is a "AETNA PROVIDER ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 854184 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P0460470 . This is a "BCBS OF ARIZONA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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