Basic Information
| Provider Information | |||||||||
| NPI: | 1851317044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPEAS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | OWEN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 957 BLACK DRIVE #A | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863051403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287789898 | ||||||||
| FaxNumber: | 9277719159 | ||||||||
| Practice Location | |||||||||
| Address1: | 957 BLACK DRIVE #A | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863051403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287789898 | ||||||||
| FaxNumber: | 9287719159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 960 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00340387 | 01 | AZ | RAILROAD MEDICARE PIN | OTHER |