Provider Demographics
NPI:1689749814
Name:ROADRUNNER REHAB INCORPORATED
Entity Type:Organization
Organization Name:ROADRUNNER REHAB INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-348-4220
Mailing Address - Street 1:2290 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-4081
Mailing Address - Country:US
Mailing Address - Phone:928-348-4220
Mailing Address - Fax:928-348-4234
Practice Address - Street 1:2290 W 16TH ST
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4081
Practice Address - Country:US
Practice Address - Phone:928-348-4220
Practice Address - Fax:928-348-4234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ078726Medicaid
AZ078726Medicaid