MEDICARE: PINNACLE SPORTS THERAPY LLC.

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	261QP2000X	Physical Therapy Clinic/Center	8092	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1275584567	OTHER		NPI

General Provider Information

NPI Number	:	1811439029
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINNACLE SPORTS THERAPY LLC.

Provider Business Mailing Address
First Line	:	425 E PINNACLE PEAK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-5657
Country	:	US
Telephone Number	:	602-283-3360
Fax Number	:	602-283-3361

Provider Business Practice Location Address
First Line	:	425 E PINNACLE PEAK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-5657
Country	:	US
Telephone Number	:	602-283-3360
Fax Number	:	602-283-3361

Authorized Official
Title or Position	:	OWNER/ CLINIC DIRECTOR
Name	:	JUSTIN SAMPLEY
Credential	:	P.T.
Telephone Number	:	602-283-3360

Provider Enumeration Date	:	11/06/2016
Last Update Date	:	05/10/2017

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