Provider Demographics
NPI:1073139986
Name:GYMPHYSIO LLC
Entity Type:Organization
Organization Name:GYMPHYSIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:TYEE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:314-537-4958
Mailing Address - Street 1:7537 S RAINBOW BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-0504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7537 S RAINBOW BLVD STE 109
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-0504
Practice Address - Country:US
Practice Address - Phone:702-459-2424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty