Provider Demographics
NPI:1386644599
Name:WHITE TANKS PHYSICAL THERAPY & ORTHO REHAB
Entity Type:Organization
Organization Name:WHITE TANKS PHYSICAL THERAPY & ORTHO REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:G
Authorized Official - Last Name:LUJAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-882-9787
Mailing Address - Street 1:2882 W GAIL DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-3963
Mailing Address - Country:US
Mailing Address - Phone:480-704-0475
Mailing Address - Fax:
Practice Address - Street 1:WHITE TANKS PHYSICAL THERAPY AND ORTHO REHAB LLC
Practice Address - Street 2:250 N LITCHFIELD RD STE 155
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338
Practice Address - Country:US
Practice Address - Phone:623-882-9787
Practice Address - Fax:623-882-9791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ916190OtherAHCCCS
AZ103195Medicare ID - Type Unspecified