Provider Demographics
NPI:1093193716
Name:ADVANCED MEDICAL THERAPY LLC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HADDAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ICHILOV
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:602-439-3800
Mailing Address - Street 1:16075 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-2828
Mailing Address - Country:US
Mailing Address - Phone:218-966-0700
Mailing Address - Fax:
Practice Address - Street 1:15640 N 7TH ST STE 6
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-3538
Practice Address - Country:US
Practice Address - Phone:602-439-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11525261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy