Healthcare Provider Details

I. General information

NPI: 1538307277
Provider Name (Legal Business Name): WELL STREET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 N 92ND ST SUITE # 110
SCOTTSDALE AZ
85258-4534
US

IV. Provider business mailing address

16534 E GLENBROOK BLVD
FOUNTAIN HILLS AZ
85268-2302
US

V. Phone/Fax

Practice location:
  • Phone: 480-209-4844
  • Fax: 480-284-5433
Mailing address:
  • Phone: 480-209-4844
  • Fax: 480-284-5433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number5898
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON PAUL MARINO
Title or Position: FOUNDER
Credential: PT, DPT
Phone: 480-209-4844