1922086883 NPI number — MARANA PHYSICAL THERAPY LLC

Table of content: (NPI 1922086883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922086883 NPI number — MARANA PHYSICAL THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARANA PHYSICAL THERAPY LLC
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:
1922086883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9190 N COACHLINE BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85743-7359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-308-4878
Provider Business Mailing Address Fax Number:
520-308-4874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9190 N COACHLINE BLVD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85743-7359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-308-4878
Provider Business Practice Location Address Fax Number:
520-308-4874
Provider Enumeration Date:
01/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOLLOW
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
520-308-4878

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: 0460840 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 200668200 . This is a "ACS PROVIDER #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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