MEDICARE: MS. KELLY ANNE VITZ P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	7277	AZ

General Provider Information

NPI Number	:	1255466231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY ANNE VITZ P.T.

Provider Business Mailing Address
First Line	:	PO BOX 4000
Second Line	:	PHYSICAL THERAPY DEPARTMENT
City	:	POLACCA
State	:	AZ
Zip	:	86042-4000
Country	:	US
Telephone Number	:	928-737-6130
Fax Number	:	928-737-6153

Provider Business Practice Location Address
First Line	:	HWY 264 MP 388
Second Line	:	HHCC - PHYSICAL THERAPY DEPARTMENT
City	:	POLACCA
State	:	AZ
Zip	:	86042-4000
Country	:	US
Telephone Number	:	928-737-6130
Fax Number	:	928-737-6153

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/08/2007

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