Basic Information
| Provider Information | |||||||||
| NPI: | 1477807485 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPOONER PHOENIX PHYSICAL THERAPY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9097 E DESERT COVE AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808604298 | ||||||||
| FaxNumber: | 4808600356 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 E BASELINE RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850426530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022431476 | ||||||||
| FaxNumber: | 6022431010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2012 | ||||||||
| LastUpdateDate: | 06/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | SPOONER | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4805514961 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 321509 | 05 | AZ | MEDICAID |