Provider Demographics
NPI:1417981432
Name:STAR PHYSICAL THERAPY & FITNESS CENTER LLC
Entity Type:Organization
Organization Name:STAR PHYSICAL THERAPY & FITNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:COREY
Authorized Official - Last Name:ADDICOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:602-896-1312
Mailing Address - Street 1:13231 N 35TH AVE
Mailing Address - Street 2:SUITE A2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-1233
Mailing Address - Country:US
Mailing Address - Phone:602-896-1312
Mailing Address - Fax:602-896-4311
Practice Address - Street 1:13231 N 35TH AVE
Practice Address - Street 2:SUITE A2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-1233
Practice Address - Country:US
Practice Address - Phone:602-896-1312
Practice Address - Fax:602-896-4311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5198225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ69798Medicare PIN