Basic Information
| Provider Information | |||||||||
| NPI: | 1912405887 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALO VERDE PHYSICAL & SPORTS THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2002 W SUNSET DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825012285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078567021 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3003 HIGHWAY 95 STE 61 | ||||||||
| Address2: | |||||||||
| City: | BULLHEAD CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864427896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287580029 | ||||||||
| FaxNumber: | 9287580055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2018 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | MOSS | ||||||||
| AuthorizedOfficialFirstName: | TRINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3074630195 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.