Provider Demographics
NPI:1174505812
Name:LONE TREE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:LONE TREE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:LEI
Authorized Official - Last Name:BOY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:928-636-7950
Mailing Address - Street 1:1596 SUSAN A WILLIAMS WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-6172
Mailing Address - Country:US
Mailing Address - Phone:928-636-7950
Mailing Address - Fax:928-636-7951
Practice Address - Street 1:1596 SUSAN A WILLIAMS WAY
Practice Address - Street 2:SUITE D
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-6172
Practice Address - Country:US
Practice Address - Phone:928-636-7950
Practice Address - Fax:928-636-7951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ103893Medicare ID - Type Unspecified