Provider Demographics
NPI:1922084243
Name:NORTHERN ARIZONA ORTHOSPORTS PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:NORTHERN ARIZONA ORTHOSPORTS PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASUERER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MISSEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-775-2765
Mailing Address - Street 1:PO BOX 28042
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86312-8042
Mailing Address - Country:US
Mailing Address - Phone:928-775-2765
Mailing Address - Fax:928-772-9170
Practice Address - Street 1:2485 N GREAT WESTERN DR
Practice Address - Street 2:F2
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-6528
Practice Address - Country:US
Practice Address - Phone:928-775-2765
Practice Address - Fax:928-772-9170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2007-10-15
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
AZZ76275Medicare ID - Type Unspecified