1164790481 NPI number — AHWATUKEE PHYSICAL THERAPY INC

Table of content: (NPI 1164790481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164790481 NPI number — AHWATUKEE PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AHWATUKEE PHYSICAL THERAPY INC
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:
AHWATUKEE PHYSICAL THERAPY
Provider Other Organization Name Type Code:
3
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:
1164790481
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4425 E AGAVE RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85044-0620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-785-1043
Provider Business Mailing Address Fax Number:
480-785-1124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4425 E AGAVE RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85044-0620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-785-1043
Provider Business Practice Location Address Fax Number:
480-785-1124
Provider Enumeration Date:
12/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BURNESS
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
480-785-1043

Provider Taxonomy Codes

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

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

  • Identifier: PENDING . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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