Provider Demographics
NPI:1134679814
Name:BLACK CANYON PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:BLACK CANYON PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:623-363-8691
Mailing Address - Street 1:PO BOX 1515
Mailing Address - Street 2:
Mailing Address - City:BLACK CANYON CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85324-1515
Mailing Address - Country:US
Mailing Address - Phone:623-363-8691
Mailing Address - Fax:928-212-8727
Practice Address - Street 1:34301 S OLD BLACK CANYON HWY STE 7
Practice Address - Street 2:
Practice Address - City:BLACK CANYON CITY
Practice Address - State:AZ
Practice Address - Zip Code:85324-9728
Practice Address - Country:US
Practice Address - Phone:623-363-8691
Practice Address - Fax:928-212-8727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2017-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3297261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy