Provider Demographics
NPI:1649291584
Name:ROGER SURETTE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:ROGER SURETTE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-458-6331
Mailing Address - Street 1:302 EL CAMINO REAL STE 10G
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2825
Mailing Address - Country:US
Mailing Address - Phone:520-458-5105
Mailing Address - Fax:520-459-2357
Practice Address - Street 1:302 EL CAMINO REAL STE 10G
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2825
Practice Address - Country:US
Practice Address - Phone:520-458-5105
Practice Address - Fax:520-459-2357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00248760OtherRRMEDICARE
AZ2Z1712OtherHN
AZ782062Medicaid
AZZ102607Medicare PIN
AZP10542Medicare UPIN