Provider Demographics
NPI:1225472533
Name:SPOONER REHAB, PC
Entity Type:Organization
Organization Name:SPOONER REHAB, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-551-4961
Mailing Address - Street 1:9097 E DESERT COVE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6710
Mailing Address - Country:US
Mailing Address - Phone:480-551-4961
Mailing Address - Fax:480-860-0356
Practice Address - Street 1:13352 N 83RD AVE
Practice Address - Street 2:SUITE A-101
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4158
Practice Address - Country:US
Practice Address - Phone:623-979-8900
Practice Address - Fax:623-979-1809
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPOONER REHAB, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-18
Last Update Date:2013-06-18
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
AZ29090Medicare PIN