Provider Demographics
NPI:1649223306
Name:MIKRUT PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:MIKRUT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKRUT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-632-0800
Mailing Address - Street 1:13175 E HIGHWAY 169
Mailing Address - Street 2:
Mailing Address - City:DEWEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86327-7372
Mailing Address - Country:US
Mailing Address - Phone:928-632-0800
Mailing Address - Fax:928-632-8505
Practice Address - Street 1:13175 E HIGHWAY 169
Practice Address - Street 2:
Practice Address - City:DEWEY
Practice Address - State:AZ
Practice Address - Zip Code:86327-7372
Practice Address - Country:US
Practice Address - Phone:928-632-0800
Practice Address - Fax:928-632-8505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6486261QP2000X
AZ5501005426261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ915936Medicaid
AZ915936Medicaid