Healthcare Provider Details

I. General information

NPI: 1386644599
Provider Name (Legal Business Name): WHITE TANKS PHYSICAL THERAPY & ORTHO REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WHITE TANKS PHYSICAL THERAPY AND ORTHO REHAB LLC 250 N LITCHFIELD RD STE 155
GOODYEAR AZ
85338
US

IV. Provider business mailing address

2882 W GAIL DR
CHANDLER AZ
85224-3963
US

V. Phone/Fax

Practice location:
  • Phone: 623-882-9787
  • Fax: 623-882-9791
Mailing address:
  • Phone: 480-704-0475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6122
License Number StateAZ

VIII. Authorized Official

Name: MRS. SARAH G LUJAN
Title or Position: BILLING REPRESENTATIVE
Credential:
Phone: 623-882-9787