Provider Demographics
NPI:1073700175
Name:SHORT, CARVIN HENRY (PT)
Entity Type:Individual
Prefix:
First Name:CARVIN
Middle Name:HENRY
Last Name:SHORT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5553
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-5553
Mailing Address - Country:US
Mailing Address - Phone:928-782-5260
Mailing Address - Fax:928-782-0383
Practice Address - Street 1:1021 W 23RD ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8347
Practice Address - Country:US
Practice Address - Phone:928-782-5260
Practice Address - Fax:928-782-0383
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ539261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZRPT539Medicare PIN
AZZ161335Medicare PIN