Provider Demographics
NPI:1225033483
Name:PALO VERDE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PALO VERDE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-758-0029
Mailing Address - Street 1:3003 HIGHWAY 95
Mailing Address - Street 2:STE 61
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7896
Mailing Address - Country:US
Mailing Address - Phone:928-758-0029
Mailing Address - Fax:928-758-0055
Practice Address - Street 1:3003 HIWAY 95
Practice Address - Street 2:STE 61
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7896
Practice Address - Country:US
Practice Address - Phone:928-758-0029
Practice Address - Fax:928-758-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1526261QP2000X
AZ4214261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03-6580Medicare ID - Type Unspecified