Provider Demographics
NPI:1568504843
Name:DON BERLYN PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:DON BERLYN PHYSICAL THERAPY PC
Other - Org Name:PHYSICAL THERAPY AT FAC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:EVONS
Authorized Official - Last Name:BERLYN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS, MTC
Authorized Official - Phone:928-556-0776
Mailing Address - Street 1:1200 W ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-6238
Mailing Address - Country:US
Mailing Address - Phone:928-556-0776
Mailing Address - Fax:
Practice Address - Street 1:1200 W ROUTE 66
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-6238
Practice Address - Country:US
Practice Address - Phone:928-556-0776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZPT1463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1463OtherAZ PT NUMBER