Provider Demographics
NPI:1023362555
Name:PROGRESSIONS THERAPY @ COPPER MOUNTAIN INN, INC
Entity Type:Organization
Organization Name:PROGRESSIONS THERAPY @ COPPER MOUNTAIN INN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-425-5721
Mailing Address - Street 1:1100 E MONROE ST
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-1363
Mailing Address - Country:US
Mailing Address - Phone:928-425-5721
Mailing Address - Fax:928-425-3745
Practice Address - Street 1:1100 E MONROE ST
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-1363
Practice Address - Country:US
Practice Address - Phone:928-425-5721
Practice Address - Fax:928-425-3745
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COPPER MOUNTAIN INN, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-06
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC3084261QH0700X, 261QP2000X, 261QR0400X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ558471Medicaid
AZ035233Medicare Oscar/Certification
AZ035233Medicare UPIN