Provider Demographics
NPI:1831470103
Name:WING NEUROLOGICAL REHAB
Entity Type:Organization
Organization Name:WING NEUROLOGICAL REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-393-0520
Mailing Address - Street 1:1190 E MISSOURI AVE. SUITE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014
Mailing Address - Country:US
Mailing Address - Phone:480-567-6717
Mailing Address - Fax:
Practice Address - Street 1:1190 E MISSOURI AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2719
Practice Address - Country:US
Practice Address - Phone:480-567-6717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-31
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP7413261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)