Provider Demographics
NPI:1710181888
Name:LIFEFIT PHYSICAL THERAPY AND REHAB SPECIALISTS, LLC
Entity Type:Organization
Organization Name:LIFEFIT PHYSICAL THERAPY AND REHAB SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRIAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-552-2996
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:2505 HUALAPAI MOUNTAIN
Practice Address - Street 2:SUITE E
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401
Practice Address - Country:US
Practice Address - Phone:928-718-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6028650001Medicare NSC
AZ117051Medicare PIN
AZDG4656Medicare UPIN
AZDG4656Medicare PIN