Basic Information
| Provider Information | |||||||||
| NPI: | 1962834895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REILLY | ||||||||
| FirstName: | GARRETT | ||||||||
| MiddleName: | BEAU | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 S FLORENCE ST | ||||||||
| Address2: | APT B | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860015475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284997311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3150 N WINDING BROOK RD | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860010972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287747106 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2013 | ||||||||
| LastUpdateDate: | 08/01/2013 | ||||||||
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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 | 10448 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.