Healthcare Provider Details

I. General information

NPI: 1114274784
Provider Name (Legal Business Name): ADULT AND PEDIATRIC REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 04/01/2024
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1453 N MAIN STREET 7
SAN LUIS AZ
85349
US

IV. Provider business mailing address

PO BOX 5841
YUMA AZ
85366-2490
US

V. Phone/Fax

Practice location:
  • Phone: 928-722-6050
  • Fax: 928-722-6094
Mailing address:
  • Phone: 928-722-6050
  • Fax: 928-722-6094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberC001071
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4229
License Number StateAZ

VIII. Authorized Official

Name: SERGIO IVAN MACIAS
Title or Position: OWNER
Credential: P.T.
Phone: 928-722-6050