Healthcare Provider Details

I. General information

NPI: 1912910522
Provider Name (Legal Business Name): JOHN JAMES BODINE PT, OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S DOBSON RD STE 314
MESA AZ
85202-4752
US

IV. Provider business mailing address

1500 S DOBSON RD STE 314
MESA AZ
85202-4752
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-7879
  • Fax: 480-844-8411
Mailing address:
  • Phone: 480-833-7879
  • Fax: 480-844-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1328
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: