Healthcare Provider Details

I. General information

NPI: 1982508834
Provider Name (Legal Business Name): PREMIER THERAPY AZ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 N 19TH AVE UNIT B
PHOENIX AZ
85021-5161
US

IV. Provider business mailing address

570 VILLAGE CENTER DR STE 205
BURR RIDGE IL
60527-4526
US

V. Phone/Fax

Practice location:
  • Phone: 630-920-4670
  • Fax:
Mailing address:
  • Phone: 630-920-4670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: KRYSTAL VAUGHN
Title or Position: BUSINESS DEVELOPMENT/HR
Credential:
Phone: 630-920-4670