Provider Demographics
NPI:1265104152
Name:ASPEN REHAB PLLC
Entity type:Organization
Organization Name:ASPEN REHAB PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BALOUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-868-5532
Mailing Address - Street 1:PO BOX 2510
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85214-2510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1851 N GEMINI DR STE A
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1607
Practice Address - Country:US
Practice Address - Phone:480-821-9339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty