Healthcare Provider Details

I. General information

NPI: 1649698945
Provider Name (Legal Business Name): BLACK RIDGE PHYSICAL THERAPY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 S 13TH WEST
SAINT JOHNS AZ
85936
US

IV. Provider business mailing address

PO BOX 824
SAINT JOHNS AZ
85936-0824
US

V. Phone/Fax

Practice location:
  • Phone: 928-337-3020
  • Fax: 928-337-3979
Mailing address:
  • Phone: 928-337-3020
  • Fax: 928-337-3979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number8544
License Number StateAZ

VIII. Authorized Official

Name: CARL S WILTBANK
Title or Position: OWNER
Credential: DPT
Phone: 928-337-3020