Healthcare Provider Details

I. General information

NPI: 1831149913
Provider Name (Legal Business Name): CANYON PHYSICAL THERAPY AND AQUATIC REHABILITATION, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2852 N NAVAJO DR SUITE A
PRESCOTT VALLEY AZ
86314-4963
US

IV. Provider business mailing address

2852 N NAVAJO DR SUITE A
PRESCOTT VALLEY AZ
86314-4963
US

V. Phone/Fax

Practice location:
  • Phone: 928-772-9797
  • Fax: 928-772-9340
Mailing address:
  • Phone: 928-772-9797
  • Fax: 928-772-9340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KELLY GERRIT VREDEVELD
Title or Position: MANAGER
Credential: D.P.T.
Phone: 928-772-9797