Basic Information
| Provider Information | |||||||||
| NPI: | 1912413857 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PR ACQUISITION CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SELECT PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4714 GETTYSBURG RD | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179721100 | ||||||||
| FaxNumber: | 7179759981 | ||||||||
| Practice Location | |||||||||
| Address1: | 2650 N TENAYA WAY STE 180 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891281110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022402952 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2017 | ||||||||
| LastUpdateDate: | 12/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | TARVIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7179721100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SELECT MEDICAL CORPORATION | ||||||||
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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 | PENDING | 05 | NV | MEDICAID |