Provider Demographics
NPI:1558429860
Name:MAXIMUM POTENTIAL SPORT & FITNESS TRAINING INC.
Entity Type:Organization
Organization Name:MAXIMUM POTENTIAL SPORT & FITNESS TRAINING INC.
Other - Org Name:FYZICAL THERAPY & BALANCE CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:602-404-8012
Mailing Address - Street 1:PO BOX 30216
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85046-0216
Mailing Address - Country:US
Mailing Address - Phone:602-404-8012
Mailing Address - Fax:602-404-7195
Practice Address - Street 1:5410 E HIGH ST STE 107
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-5457
Practice Address - Country:US
Practice Address - Phone:602-404-8012
Practice Address - Fax:602-404-7195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4376261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ115420Medicare PIN