Healthcare Provider Details

I. General information

NPI: 1033994736
Provider Name (Legal Business Name): BASECAMP PHYSICAL THERAPY AND PERFORMANCE OF FLAGSTAFF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 S WOODLANDS VILLAGE BLVD STE 750
FLAGSTAFF AZ
86001-1628
US

IV. Provider business mailing address

2619 S WOODLANDS VILLAGE BLVD STE 750
FLAGSTAFF AZ
86001-1628
US

V. Phone/Fax

Practice location:
  • Phone: 928-224-0747
  • Fax: 928-224-0802
Mailing address:
  • Phone: 928-224-0747
  • Fax: 928-224-0802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LOGAN MADDING
Title or Position: DIRECTOR OF BUSINESS OPERATIONS
Credential:
Phone: 928-224-0747