Provider Demographics
NPI:1306036033
Name:SHANGRI-LA PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SHANGRI-LA PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:520-826-3222
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:PEARCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85625-0304
Mailing Address - Country:US
Mailing Address - Phone:520-826-3222
Mailing Address - Fax:520-826-3222
Practice Address - Street 1:105 FRONTAGE RD
Practice Address - Street 2:STE F
Practice Address - City:PEARCE
Practice Address - State:AZ
Practice Address - Zip Code:85625
Practice Address - Country:US
Practice Address - Phone:520-826-3222
Practice Address - Fax:520-826-3222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1500261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ783078Medicaid
AZR32516Medicare UPIN
AZ783078Medicaid