Basic Information
| Provider Information | |||||||||
| NPI: | 1760944433 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPOONER PHYSICAL THERAPY & HAND REHAB PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPOONER MCCORMICK RANCH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 8415 N PIMA RD STE 165 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809094777 | ||||||||
| FaxNumber: | 4809094778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| 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: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 324787 | 05 | AZ | MEDICAID |