Provider Demographics
NPI:1528536554
Name:PICACHO 1, LLC
Entity Type:Organization
Organization Name:PICACHO 1, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:FLOYD
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-495-6574
Mailing Address - Street 1:20715 E OCOTILLO RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142
Mailing Address - Country:US
Mailing Address - Phone:480-495-6574
Mailing Address - Fax:480-888-1533
Practice Address - Street 1:20715 E OCOTILLO RD
Practice Address - Street 2:SUITE 103
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142
Practice Address - Country:US
Practice Address - Phone:480-495-6574
Practice Address - Fax:480-888-1533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty