Provider Demographics
NPI:1265664312
Name:ORTHOMED, LLC
Entity Type:Organization
Organization Name:ORTHOMED, LLC
Other - Org Name:PROACTIVE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-321-0204
Mailing Address - Street 1:P.O. BOX 64207
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85728
Mailing Address - Country:US
Mailing Address - Phone:480-706-1161
Mailing Address - Fax:480-706-7997
Practice Address - Street 1:8770 N. THORNYDALE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85742
Practice Address - Country:US
Practice Address - Phone:520-742-7107
Practice Address - Fax:520-742-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2016-11-16
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
AZ825036Medicaid
AZ825036Medicaid