Basic Information
| Provider Information | |||||||||
| NPI: | 1639712110 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA ORTHOPEDIC PHYSICAL THERAPY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14557 W INDIAN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853959218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232426908 | ||||||||
| FaxNumber: | 6232426909 | ||||||||
| Practice Location | |||||||||
| Address1: | 1781 E STATE HIGHWAY 69 | ||||||||
| Address2: | SUITE 28 | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232426908 | ||||||||
| FaxNumber: | 6232426909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2019 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | RYANN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6232426908 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARIZONA ORTHOPEDIC PHYSICAL THERAPY, PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 156886 | 05 | AZ | MEDICAID |