Provider Demographics
NPI:1326038118
Name:SANDERSON & DUBOIS MOMENTUM PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SANDERSON & DUBOIS MOMENTUM PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBOIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, CSCS
Authorized Official - Phone:520-733-6227
Mailing Address - Street 1:6206 E PIMA ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-7000
Mailing Address - Country:US
Mailing Address - Phone:520-733-6227
Mailing Address - Fax:520-733-7328
Practice Address - Street 1:6206 E PIMA ST
Practice Address - Street 2:SUITE 3
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-7000
Practice Address - Country:US
Practice Address - Phone:520-733-6227
Practice Address - Fax:520-733-7328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2011-02-15
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
AZ109950OtherAHCCCS
AZAZ0460450OtherBCBS OF AZ
AZ2Z3779OtherHEALTH NET OF AZ
AZ189339600OtherUS DEPT OF LABOR
AZZWMBRRMedicare ID - Type Unspecified