Provider Demographics
NPI:1407049331
Name:PHYSICAL THERAPY CLINIC OF GOLD CANYON
Entity Type:Organization
Organization Name:PHYSICAL THERAPY CLINIC OF GOLD CANYON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CHURCHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-983-2259
Mailing Address - Street 1:6410 S KINGS RANCH RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-7352
Mailing Address - Country:US
Mailing Address - Phone:480-983-2259
Mailing Address - Fax:480-983-2259
Practice Address - Street 1:6410 S KINGS RANCH RD
Practice Address - Street 2:SUITE 2
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-7352
Practice Address - Country:US
Practice Address - Phone:480-983-2259
Practice Address - Fax:480-983-2259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ378225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0292230OtherBLUE CROSS/BLUE SHIELD
AZ670001707OtherRAIL ROAD MEDICARE
AZAZ0292230OtherBLUE CROSS/BLUE SHIELD
AZ=========OtherTRICARE/WPS