Basic Information
| Provider Information | |||||||||
| NPI: | 1932430949 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 360 PHYSICAL THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8670 E SHEA BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806079200 | ||||||||
| FaxNumber: | 4806079207 | ||||||||
| Practice Location | |||||||||
| Address1: | 8670 E SHEA BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806079200 | ||||||||
| FaxNumber: | 4806079207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2010 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/26/2021 | ||||||||
| NPIReactivationDate: | 09/09/2021 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUNNEL | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS | ||||||||
| AuthorizedOfficialTelephone: | 4808211997 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 5497 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 616922 | 05 | AZ | MEDICAID | 66833 | 01 | AZ | MEDICARE IDENITIFCATION NUMBER | OTHER |