Provider Demographics
NPI:1982887113
Name:PONGRATZ PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PONGRATZ PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PONGRATZ
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:602-222-3032
Mailing Address - Street 1:641 W SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-5004
Mailing Address - Country:US
Mailing Address - Phone:602-222-3032
Mailing Address - Fax:480-615-1117
Practice Address - Street 1:641 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5004
Practice Address - Country:US
Practice Address - Phone:602-222-3032
Practice Address - Fax:480-615-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5241225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ81712OtherMEDICARE GROUP PIN
AZ864399Medicaid
AZ81712OtherMEDICARE GROUP PIN