Provider Demographics
NPI:1326091455
Name:ADVANCED MEDICAL THERAPY, LLC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HADDAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ICHILOV
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:602-439-3800
Mailing Address - Street 1:15640 NORTH 7TH STREET
Mailing Address - Street 2:STE 6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022
Mailing Address - Country:US
Mailing Address - Phone:602-439-3800
Mailing Address - Fax:602-439-3802
Practice Address - Street 1:15640 NORTH 7TH STREET
Practice Address - Street 2:STE 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022
Practice Address - Country:US
Practice Address - Phone:602-439-3800
Practice Address - Fax:602-439-3802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC 3834261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ944349Medicaid
AZAZ0463990OtherBLUE CROSS
AZ034523Medicare Oscar/Certification