Provider Demographics
NPI:1649698945
Name:BLACK RIDGE PHYSICAL THERAPY, PLC
Entity type:Organization
Organization Name:BLACK RIDGE PHYSICAL THERAPY, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILTBANK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:928-337-3020
Mailing Address - Street 1:PO BOX 824
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:AZ
Mailing Address - Zip Code:85936-0824
Mailing Address - Country:US
Mailing Address - Phone:928-337-3020
Mailing Address - Fax:928-337-3979
Practice Address - Street 1:80 S 13TH WEST
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:AZ
Practice Address - Zip Code:85936
Practice Address - Country:US
Practice Address - Phone:928-337-3020
Practice Address - Fax:928-337-3979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8544261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ443777Medicaid
AZZ131189OtherMEDICARE