Provider Demographics
NPI:1710071469
Name:PHYSICAL THERAPY SPECIALIST
Entity Type:Organization
Organization Name:PHYSICAL THERAPY SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, OCS
Authorized Official - Phone:775-782-4422
Mailing Address - Street 1:1625 HWY 88
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MINDEN
Mailing Address - State:NV
Mailing Address - Zip Code:89423
Mailing Address - Country:US
Mailing Address - Phone:775-782-4422
Mailing Address - Fax:775-782-4232
Practice Address - Street 1:1625 HWY 88
Practice Address - Street 2:SUITE 302
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423
Practice Address - Country:US
Practice Address - Phone:775-782-4422
Practice Address - Fax:775-782-4232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1281261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV36859Medicare PIN
NV1346234218Medicare ID - Type UnspecifiedNPI NUMBER
NVV103510Medicare PIN