Healthcare Provider Details

I. General information

NPI: 1134679814
Provider Name (Legal Business Name): BLACK CANYON PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 02/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34301 S OLD BLACK CANYON HWY STE 7
BLACK CANYON CITY AZ
85324-9728
US

IV. Provider business mailing address

PO BOX 1515
BLACK CANYON CITY AZ
85324-1515
US

V. Phone/Fax

Practice location:
  • Phone: 623-363-8691
  • Fax: 928-212-8727
Mailing address:
  • Phone: 623-363-8691
  • Fax: 928-212-8727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number3297
License Number StateAZ

VIII. Authorized Official

Name: MR. GREGG POTTER
Title or Position: MEMBER
Credential: PT
Phone: 623-363-8691