Provider Demographics
NPI:1518937325
Name:HIGH DESERT PHYSICAL THERAPY AND SPORTS REHABILITATION, PLLC
Entity Type:Organization
Organization Name:HIGH DESERT PHYSICAL THERAPY AND SPORTS REHABILITATION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/P.T.
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:928-289-4378
Mailing Address - Street 1:221 W SECOND ST
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-3564
Mailing Address - Country:US
Mailing Address - Phone:928-289-4378
Mailing Address - Fax:928-289-5116
Practice Address - Street 1:221 W SECOND ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-3564
Practice Address - Country:US
Practice Address - Phone:928-289-4378
Practice Address - Fax:928-289-5116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ788599Medicaid
AZ094792Medicaid
AZDA1420OtherRR MEDICARE
AZZ75082OtherMEDICARE UPIN
AZ356263Medicaid
AZZ197326OtherMEDICARE UPIN
AZ832974Medicaid
AZ982555Medicaid
AZP89817Medicare UPIN
AZQ09633Medicare UPIN
AZ788606Medicaid