Provider Demographics
NPI:1083877070
Name:SVASSAMA
Entity Type:Organization
Organization Name:SVASSAMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-445-5639
Mailing Address - Street 1:PO BOX 13159
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-3159
Mailing Address - Country:US
Mailing Address - Phone:928-445-5639
Mailing Address - Fax:928-442-0031
Practice Address - Street 1:3101 CLEARWATER DR
Practice Address - Street 2:SUITE D
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7180
Practice Address - Country:US
Practice Address - Phone:928-445-5639
Practice Address - Fax:928-442-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3833261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ554239Medicaid
AZAZ0463420OtherBCBS
AZ65039Medicare PIN
AZP29217Medicare UPIN