Provider Demographics
NPI:1710487707
Name:DESERT EDGE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:DESERT EDGE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:623-235-5772
Mailing Address - Street 1:10100 W. LAKE PLEASANT PARKWAY
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382
Mailing Address - Country:US
Mailing Address - Phone:623-334-8767
Mailing Address - Fax:623-566-5993
Practice Address - Street 1:10100 W. LAKE PLEASANT PARKWAY
Practice Address - Street 2:SUITE 1300
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382
Practice Address - Country:US
Practice Address - Phone:623-334-8767
Practice Address - Fax:623-566-5993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-15
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11446261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy