Provider Demographics
NPI:1598280059
Name:KINETIC SPORTS AND SPINE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:KINETIC SPORTS AND SPINE PHYSICAL THERAPY
Other - Org Name:KINETIC SPORTS AND SPINE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:Q
Authorized Official - Last Name:AVAKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-291-4120
Mailing Address - Street 1:9525 E DOUBLETREE RANCH RD STE 103
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5538
Mailing Address - Country:US
Mailing Address - Phone:480-291-4120
Mailing Address - Fax:
Practice Address - Street 1:9525 E DOUBLETREE RANCH RD STE 103
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5538
Practice Address - Country:US
Practice Address - Phone:480-291-4120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ104112251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty