Basic Information
| Provider Information | |||||||||
| NPI: | 1386318699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 360 PHYSICAL THERAPY LLC | ||||||||
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| OtherOrganizationName: | 360 PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1076 W CHANDLER BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808211997 | ||||||||
| FaxNumber: | 4808211887 | ||||||||
| Practice Location | |||||||||
| Address1: | 11340 W BELL RD | ||||||||
| Address2: | |||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853789342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232266644 | ||||||||
| FaxNumber: | 6235224042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2021 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | BRUNIN | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | HUNNEL | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF REVENUE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4808211997 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 360 PHYSICAL THERAPY LLC | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 300502 | 05 | AZ | MEDICAID |