Basic Information
Provider Information | |||||||||
NPI: | 1275576589 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | 360 PHYSICAL THERAPY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1076 W CHANDLER BLVD | ||||||||
Address2: | STE 103 | ||||||||
City: | CHANDLER | ||||||||
State: | AZ | ||||||||
PostalCode: | 85224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808211997 | ||||||||
FaxNumber: | 4808211887 | ||||||||
Practice Location | |||||||||
Address1: | 1076 W CHANDLER BLVD | ||||||||
Address2: | STE 103 | ||||||||
City: | CHANDLER | ||||||||
State: | AZ | ||||||||
PostalCode: | 852245225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808211997 | ||||||||
FaxNumber: | 4808211887 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 06/13/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BALDWIN | ||||||||
AuthorizedOfficialFirstName: | TRESHA | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST OWNER | ||||||||
AuthorizedOfficialTelephone: | 4808211997 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.