Basic Information
Provider Information | |||||||||
NPI: | 1114424868 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPOONER PHYSICAL THERAPY & HAND REHAB, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SPOONER SURPRISE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9097 E DESERT COVE AVE STE 110 | ||||||||
Address2: |   | ||||||||
City: | SCOTTSDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852606276 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6023298250 | ||||||||
FaxNumber: | 4805651898 | ||||||||
Practice Location | |||||||||
Address1: | 16968 W BELL RD # D401 | ||||||||
Address2: |   | ||||||||
City: | SURPRISE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853748943 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6232999190 | ||||||||
FaxNumber: | 6232999191 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2018 | ||||||||
LastUpdateDate: | 07/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SPOONER | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4805514958 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SPOONER PHYSICAL THERAPY & HAND REHAB, PC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: | 07/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   | AZ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
ID | Type | State | Issuer | Description | 324787 | 05 | AZ |   | MEDICAID |