Provider Demographics
NPI:1164790481
Name:AHWATUKEE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:AHWATUKEE PHYSICAL THERAPY INC
Other - Org Name:AHWATUKEE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNESS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:480-785-1043
Mailing Address - Street 1:4425 E AGAVE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-0620
Mailing Address - Country:US
Mailing Address - Phone:480-785-1043
Mailing Address - Fax:480-785-1124
Practice Address - Street 1:4425 E AGAVE RD STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-0620
Practice Address - Country:US
Practice Address - Phone:480-785-1043
Practice Address - Fax:480-785-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGOtherMEDICARE