Healthcare Provider Details

I. General information

NPI: 1659608198
Provider Name (Legal Business Name): JUSTIN CHARLES ST.JAMES D.P.T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 E GLENDALE AVE STE 105
PHOENIX AZ
85020-4900
US

IV. Provider business mailing address

320 W GLENEAGLES DR
PHOENIX AZ
85023-5245
US

V. Phone/Fax

Practice location:
  • Phone: 602-241-3145
  • Fax: 602-241-3146
Mailing address:
  • Phone: 602-751-7812
  • Fax: 602-266-6533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7847
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: