Healthcare Provider Details

I. General information

NPI: 1639472244
Provider Name (Legal Business Name): GILBERT PT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2010
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N GILBERT RD SUITE 309
GILBERT AZ
85234-4502
US

IV. Provider business mailing address

3004 N CIVIC CENTER PLZ
SCOTTSDALE AZ
85251-6904
US

V. Phone/Fax

Practice location:
  • Phone: 480-926-1111
  • Fax: 480-926-2958
Mailing address:
  • Phone: 480-990-7676
  • Fax: 480-990-8222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7280
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number27848
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP3957
License Number StateAZ

VIII. Authorized Official

Name: MR. JOHN M EBY
Title or Position: OWNER
Credential:
Phone: 602-679-7676