Healthcare Provider Details

I. General information

NPI: 1215931126
Provider Name (Legal Business Name): FLAGSTAFF PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 N BEAVER ST
FLAGSTAFF AZ
86001
US

IV. Provider business mailing address

715 N BEAVER ST
FLAGSTAFF AZ
86001
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-1601
  • Fax: 928-773-1603
Mailing address:
  • Phone: 928-773-1601
  • Fax: 928-773-1603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MARK WAYNE STATHAM
Title or Position: OWNER PRESIDENT
Credential: PT
Phone: 928-773-1601