Provider Demographics
NPI:1760691448
Name:CLASSICAL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:CLASSICAL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLLA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:602-443-1030
Mailing Address - Street 1:4045 N 7TH ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-4736
Mailing Address - Country:US
Mailing Address - Phone:602-443-1030
Mailing Address - Fax:602-443-1033
Practice Address - Street 1:4045 N 7TH ST
Practice Address - Street 2:SUITE 220
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4736
Practice Address - Country:US
Practice Address - Phone:602-443-1030
Practice Address - Fax:602-443-1033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
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
AZ782880Medicaid
AZ782880Medicaid