Provider Demographics
NPI:1134524234
Name:THE PHYSIO SHOP LLC
Entity type:Organization
Organization Name:THE PHYSIO SHOP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DPT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:DORSCH
Authorized Official - Suffix:
Authorized Official - Credentials:AT, DPT
Authorized Official - Phone:928-214-7303
Mailing Address - Street 1:1510 S. RIORDAN RANCH ST.
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-214-7303
Mailing Address - Fax:928-214-0696
Practice Address - Street 1:1510 S. RIORDAN RANCH ST.
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-214-7303
Practice Address - Fax:928-214-0696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9032225100000X
261QP2000X, 261QP2000X
AZ6213225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ126915Medicaid