Provider Demographics
NPI:1790887255
Name:PACE, VIVIAN M (MPT)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:M
Last Name:PACE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3748
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-3748
Mailing Address - Country:US
Mailing Address - Phone:928-567-0987
Mailing Address - Fax:928-567-5562
Practice Address - Street 1:522 W FINNIE FLATS RD STE D
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7265
Practice Address - Country:US
Practice Address - Phone:928-567-0987
Practice Address - Fax:928-567-5562
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2149261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ131904Medicaid
AZZRPT2149Medicare ID - Type Unspecified
AZS20611Medicare UPIN