Provider Demographics
NPI:1821490525
Name:ARIZONA THERAPEUTIC WELLNESS
Entity Type:Organization
Organization Name:ARIZONA THERAPEUTIC WELLNESS
Other - Org Name:AQUA THERAPY CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:ECTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-773-7766
Mailing Address - Street 1:2571 S VAL VISTA DR
Mailing Address - Street 2:101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6232
Mailing Address - Country:US
Mailing Address - Phone:480-773-7766
Mailing Address - Fax:480-773-6737
Practice Address - Street 1:2571 S VAL VISTA DR
Practice Address - Street 2:101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-6232
Practice Address - Country:US
Practice Address - Phone:480-773-7766
Practice Address - Fax:480-773-6737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10792225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1065857OtherTUFTS
MA1065857OtherAETNA
MAY67447OtherBC
MAY69537OtherMEDICARE UNSPECIFIED