Basic Information
Provider Information
NPI: 1205103694
EntityType: 2
ReplacementNPI:  
OrganizationName: PT CRUIZER LLC
LastName:  
FirstName:  
MiddleName:  
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NameSuffix:  
Credential:  
OtherOrganizationName:  
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Mailing Information
Address1: 12550 W CAMPINA DR
Address2:  
City: LITCHFIELD PARK
State: AZ
PostalCode: 853405171
CountryCode: US
TelephoneNumber: 6025768666
FaxNumber:  
Practice Location
Address1: 12550 W CAMPINA DR
Address2:  
City: LITCHFIELD PARK
State: AZ
PostalCode: 853405171
CountryCode: US
TelephoneNumber: 6025768666
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/29/2011
LastUpdateDate: 11/29/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: PELLMAN
AuthorizedOfficialFirstName: MARK
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: MEMBER
AuthorizedOfficialTelephone: 6024726330
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QP2000X  Y Ambulatory Health Care FacilitiesClinic/CenterPhysical Therapy

No ID Information.


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