Healthcare Provider Details

I. General information

NPI: 1104506203
Provider Name (Legal Business Name): THE PLATFORM PERFORMANCE AND SPORTS REHAB, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/24/2023
Certification Date: 07/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8996 W UNION HILLS DR STE 107
PEORIA AZ
85382-3010
US

IV. Provider business mailing address

15102 N 90TH AVE
PEORIA AZ
85381-3520
US

V. Phone/Fax

Practice location:
  • Phone: 602-717-9361
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: HAILEY KAUS
Title or Position: PT / CO-OWNER
Credential:
Phone: 602-717-9361