Provider Demographics
NPI:1114274784
Name:ADULT AND PEDIATRIC REHABILITATION
Entity Type:Organization
Organization Name:ADULT AND PEDIATRIC REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-722-6050
Mailing Address - Street 1:PO BOX 5841
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2490
Mailing Address - Country:US
Mailing Address - Phone:928-722-6050
Mailing Address - Fax:928-722-6094
Practice Address - Street 1:1453 N MAIN STREET
Practice Address - Street 2:7
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-722-6050
Practice Address - Fax:928-722-6094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4229225100000X
AZC001071332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ729459Medicaid
AZ6851710001Medicare PIN
AZ729459Medicaid