Provider Demographics
NPI:1891898177
Name:CAMP VERDE PHYSICAL REHABILTATION
Entity Type:Organization
Organization Name:CAMP VERDE PHYSICAL REHABILTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PACE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:928-567-0987
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 WEST FINNEY FLATS RD, SUITE D
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322
Practice Address - Country:US
Practice Address - Phone:928-567-0987
Practice Address - Fax:928-567-5562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
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
AZ131904Medicaid
AZS20611Medicare UPIN