Healthcare Provider Details

I. General information

NPI: 1750385654
Provider Name (Legal Business Name): WHITE MOUNTAIN PHYSICAL THERAPY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 W MCNEIL
SHOW LOW AZ
85901-5838
US

IV. Provider business mailing address

PO BOX 1420
SHOW LOW AZ
85902-1420
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-8196
  • Fax: 928-532-8860
Mailing address:
  • Phone: 928-537-8196
  • Fax: 928-532-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL LYNN JOHNSON
Title or Position: CO-OWNER
Credential: P.T.
Phone: 928-537-8196