Provider Demographics
NPI:1215931126
Name:FLAGSTAFF PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:FLAGSTAFF PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:STATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-773-1601
Mailing Address - Street 1:715 N BEAVER 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:928-773-1601
Mailing Address - Fax:928-773-1603
Practice Address - Street 1:715 N BEAVER 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:928-773-1601
Practice Address - Fax:928-773-1603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ68827Medicare UPIN