Provider Demographics
NPI:1942728340
Name:VALLEY REHABILITATION OF SUN CITY
Entity Type:Organization
Organization Name:VALLEY REHABILITATION OF SUN CITY
Other - Org Name:VALLEY REHABILITATION OF SUN CITY WEST, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING & OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LACY
Authorized Official - Middle Name:LA NETTE'
Authorized Official - Last Name:WYSOPAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-546-6712
Mailing Address - Street 1:14300 W GRANITE VALLEY DR STE E21
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-5798
Mailing Address - Country:US
Mailing Address - Phone:623-546-6712
Mailing Address - Fax:623-546-6739
Practice Address - Street 1:14300 W GRANITE VALLEY DR STE E21
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5798
Practice Address - Country:US
Practice Address - Phone:623-546-6712
Practice Address - Fax:623-546-6739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2Z2293OtherHEALTH NET
AZP00121650OtherRAILROAD MEDICARE
AZ1161706OtherASH
AZ719049OtherAHCCCS
AZ326111Medicaid
AZ4428261OtherAETNA
AZP02039084OtherRAILROAD MEDICARE
AZ326111OtherAHCCCS