1578971198 NPI number — MDR PHYSICAL THERAPY, INC

Table of content: (NPI 1578971198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578971198 NPI number — MDR PHYSICAL THERAPY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MDR 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:
AGILITY SPINE AND SPORTS 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:
1578971198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1777 W ST. MARY'S ROAD
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:
85745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-884-9819
Provider Business Mailing Address Fax Number:
520-884-0175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1605 E RIVER ROAD, SUITE 201
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:
85719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-884-9819
Provider Business Practice Location Address Fax Number:
520-884-0175
Provider Enumeration Date:
07/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
NOLAN BELANGER
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
520-884-9819

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)





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