Basic Information
Provider Information | |||||||||
NPI: | 1871602672 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOYCE | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | PAUL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17897 E CINDERCONE RD | ||||||||
Address2: |   | ||||||||
City: | RIO VERDE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852635386 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4079028178 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8405 N PIMA CENTER PKWY STE 101 | ||||||||
Address2: |   | ||||||||
City: | SCOTTSDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852584669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029229222 | ||||||||
FaxNumber: | 6028890569 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2006 | ||||||||
LastUpdateDate: | 10/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | LPT-30125 | AZ | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | LPT-30125 | 01 | AZ | ARIZONA STATE BOARD OF PHYSICAL THERAPY | OTHER |