Healthcare Provider Details

I. General information

NPI: 1124176342
Provider Name (Legal Business Name): SOUTH MOUNTAIN REHABILITATION P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4804 E CHANDLER BLVD 106
PHOENIX AZ
85048-0857
US

IV. Provider business mailing address

16016 S 45TH PL
PHOENIX AZ
85048-7635
US

V. Phone/Fax

Practice location:
  • Phone: 480-893-6020
  • Fax: 480-785-5161
Mailing address:
  • Phone: 480-759-1082
  • Fax: 480-785-5161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5302
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2853
License Number StateAZ

VIII. Authorized Official

Name: DR. PETER VINCENT PAKULIS
Title or Position: PRESIDENT
Credential: D.C.,P.T.
Phone: 480-759-1082