Provider Demographics
NPI:1164506416
Name:DEROSA PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:DEROSA PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DEROSA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-774-6626
Mailing Address - Street 1:1485 N. TURQUOISE DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-774-6626
Mailing Address - Fax:928-214-3277
Practice Address - Street 1:1485 N. TURQUOISE DR
Practice Address - Street 2:SUITE 220
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-774-6626
Practice Address - Fax:928-214-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ767225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ29027Medicare ID - Type Unspecified